title: Surveillance Endomyocardial Biopsy in the Modern Era Produces Low Diagnostic Yield for Cardiac Allograft Rejection.
abstract: BACKGROUND
  The changing epidemiology of cardiac allograft rejection has prompted many to question the yield of surveillance endomyocardial biopsy (EMB) in heart transplantation (HT) patients. We sought to determine the yield of EMB in the modern era.
  
  
  METHODS
  We evaluated 2597 EMBs in 182 consecutive HT patients who survived to their first EMB. The EMBs were categorized as asymptomatic or clinically driven and were compared based on era of antiproliferative therapy use at our center (early azathioprine era: 1990-2000 vs modern mycophenolate era: 2000-2011).
  
  
  RESULTS
  In the modern era, patients had a higher prevalence of risk factors for developing rejection (≥ International Society of Heart and Lung Transplantation grade 2R); however, the frequency of rejection was decreased at all times (0-6 months: 60.2% vs 21.5%, P < 0.001, 6-12 months: 26.8% vs 1.8%, P < 0.001, 12-36 months: 32.3% vs 10.5%, P = 0.006). The yield of asymptomatic EMB decreased in the modern era between 0 and 6 months (10.9% vs 3.12%), 6 to 12 months (17% vs 0%), and years 2 to 3 (6.1% vs 1.5%). In the early era, the odds ratio of rejection during asymptomatic EMB compared to a clinically driven EMB was 0.47 (95% confidence interval, 0.31-0.71) and was decreased in the modern era (0.17 [0.07-0.42], P = 0.04). The probability of detecting rejection on asymptomatic EMB was significantly reduced in the modern era, even after adjustment for tacrolimus and induction therapy (1% vs 8%, P < 0.001).
  
  
  CONCLUSIONS
  The clinical yield of surveillance EMB has decreased in the modern era. The EMB in asymptomatic patients longer than 6 months after HT warrants further scrutiny.
authors.affiliation: 1 Division of Cardiology, Virginia Commonwealth University, Richmond, VA. 2 Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA. 3 Department of Biostatistics, Virginia Commonwealth University, Richmond, VA.
authors.forename: Keyur B
authors.initials: KB
authors.lastname: Shah
authors.forename: Maureen P
authors.initials: MP
authors.lastname: Flattery
authors.forename: Melissa C
authors.initials: MC
authors.lastname: Smallfield
authors.forename: Grace
authors.initials: G
authors.lastname: Merinar
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Tang
authors.forename: Emily H
authors.initials: EH
authors.lastname: Sheldon
authors.forename: Leroy R
authors.initials: LR
authors.lastname: Thacker
authors.forename: Vigneshwar
authors.initials: V
authors.lastname: Kasirajan
authors.forename: Richard H
authors.initials: RH
authors.lastname: Cooke
authors.forename: Michael L
authors.initials: ML
authors.lastname: Hess
mesh_terms: D000328:Adult; D001706:Biopsy; D005260:Female; D006084:Graft Rejection / Q000276:immunology / Q000401:mortality / Q000473:pathology* / Q000517:prevention & control; D016027:Heart Transplantation / Q000009:adverse effects* / Q000401:mortality; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology*; D016017:Odds Ratio; D011237:Predictive Value of Tests; D015995:Prevalence; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014768:Virginia / Q000453:epidemiology
chemical_list: D007166:Immunosuppressive Agents