Diagnostic pitfalls and challenges in interpretation of heart transplantation rejection in endomyocardial biopsies with focus on our experience

Abstract

Background:The current trend of heart transplantation in recent years has taken a quantum leap forward. We decided to look back at our experience in this center.Objectives:Here, we focus on the diagnostic pitfalls and challenges in these biopsies.Patients and Methods:Forty two patients based on the standard protocol of heart transplantation group, yielded 63 biopsy samples over a period of 33 months (April 2010 - December 2012). The mean age was 30.4 years (ranging from 16 to 58 years) with 51 males (81%) and 12 females (19%). All the patients were examined periodically and biopsy samples were taken from the right ventricular wall.Results:Rarely fewer than three pieces of myocardial samples were procured. Scar, adipose tissues and blood clots may be seen instead. Quilty effect (nodular endocardial lesions composed of inflammatory cell infiltrates) was seen in 8 cases (12.7%). Other findings not directly related to rejection including early ischemic injury, Quilty effect and post-transplant lymphoproliferative disorders (PTLD) were not encountered.Conclusions:Specimen inadequacy was not a major problem in our center. It poses a great limitation, because suboptimal specimens sometimes mislead the pathologist. Other findings especially Quilty effect were within the range defined for this finding.

Quilty Effect: Its Definition and Significance, in Post-Cardiac Transplant Endomyocardial Biopsies with Focus on Our Experience

“…Similarly, in our specimens, as presented in the results section, quilty effect was found in 12.7% of samples, which is within the range defined in other studies (1,2,5).…”

“…This lesion is benign and should be differentiated from acute rejection. Further immunosuppression treatment is not needed (1).…”

“…Be that as it may, based on the general transplant protocol, patients are needed to undergo biopsy every month in the first year after transplantation; unless the existence of clinically suspected rejection leads to additional sampling (1).…”

“…Sixty-three biopsy samples were acquired for monitoring acute transplant rejection in the abovementioned group. All of the patients were planned for endomyocardial biopsy based on the guidelines of "international society for heart and lung transplantation (ISHLT)" (1).…”

“…We expected that diagnostic challenges were to be noted in the interpretation of endomyocardial biopsies of the patients who are being assessed for their rejection status histopathologically. With this fact borne in mind, we decided to review the cases from this point of view (1).…”