Outcomes of low-intensity biopsy surveillance for rejection in paediatric cardiac transplantation

Abstract

Background:Significant inter-centre variability in the intensity of endomyocardial biopsy surveillance for rejection following paediatric cardiac transplantation has been reported. Our aim was to determine if low-intensity biopsy surveillance with two scheduled biopsies in the first year would produce outcomes similar to published registry outcomes.Methods:A retrospective study of paediatric recipients transplanted between 2008 and 2014 using a low-intensity biopsy protocol consisting of two surveillance biopsies at 3 and 12–13 months in the first post-transplant year, then annually thereafter. Additional biopsies were performed based on echocardiographic and clinical surveillance. Excluded were recipients that were re-transplanted or multi-organ transplanted or were followed at another institution.Results:A total of 81 recipients in the first 13 months after transplant underwent an average of 2 (SD ± 1.3) biopsies, 24 ± 6.8 echocardiograms, and 17 ± 4.4 clinic visits per recipient. During the 13-month period, 19 recipients had 24 treated rejection episodes, with the first at an average of 2.8 months post-transplant. The 3-, 12-, 36-, and 60-month conditional on discharge graft survival were 100%, 98.8%, 98.8%, and 90.4%, respectively, comparable to reported figures in major paediatric registries. At a mean follow-up of 4.7 ± 2.1 years, four patients (4.9%) developed cardiac allograft vasculopathy, three (3.7%) developed a malignancy, and seven (8.6%) suffered graft loss.Conclusion:Rejection surveillance with a low-intensity biopsy protocol demonstrated similar intermediate-term outcomes and safety measures as international registries up to 5 years post-transplant.

Rejection surveillance in pediatric heart transplant recipients: Critical reflection on the role of frequent and long‐term routine surveillance endomyocardial biopsies and comprehensive review of non‐invasive rejection screening tools

“…Evers et al reported outcomes from their center demonstrating that a low‐intensity RSB schedule (two in the first year and annually thereafter) produced intermediate‐term outcomes similar to published registry outcomes up to 5‐year post‐HT 39 …”

“…Evers et al reported outcomes from their center demonstrating that a low-intensity RSB schedule (two in the first year and annually thereafter) produced intermediate-term outcomes similar to published registry outcomes up to 5-year post-HT. 39 Keypoint: The available evidence suggests that a reduction in RSB intensity from high-frequency to low-frequency can be done safely with no impact on early and mid-term survival. Unfortunately, there is a paucity of pediatric data evaluating long-term outcomes (beyond the first 5 years) stratified by RSB intensity.…”

Native T1 mapping detects both acute clinical rejection and graft dysfunction in pediatric heart transplant patients

“…Using a larger population and whole-heart imaging, we have demonstrated a difference in T1 values between cases of rejection and cases without rejection, when rejection is defined clinically by necessity of treatment rather than exclusively by biopsy grade. Further, due to significant inter-center variability in the frequency of EMB for rejection surveillance, prior studies have investigated the yield of EMB and its impact on outcomes in the pediatric population [ 46 , 47 ]. Studies investigating frequency of EMB both in the first year post-transplantation [ 47 ] when rejection risk is highest as well as long-term routine surveillance [ 46 ], demonstrated similar outcomes between high intensity and low intensity protocols.…”

“…Further, due to significant inter-center variability in the frequency of EMB for rejection surveillance, prior studies have investigated the yield of EMB and its impact on outcomes in the pediatric population [ 46 , 47 ]. Studies investigating frequency of EMB both in the first year post-transplantation [ 47 ] when rejection risk is highest as well as long-term routine surveillance [ 46 ], demonstrated similar outcomes between high intensity and low intensity protocols. Adult studies have supported discontinuing routine EMB for long-term surveillance [ 48 , 49 ].…”

“To biopsy, or not to biopsy”? That is the clinical conundrum

“…Since these cases are elective and likely scheduled surveillance, the question for the practitioner is can non‐invasive markers for rejection largely replace the need for a scheduled surveillance biopsy? Is there precedence in centers performing less surveillance biopsies without inferior outcomes? 2,3 And if the patient has no findings to suggest rejection, not admitted, or the biopsy is not deemed “urgent”, would the practitioner treat for rejection if the histology meets certain pre‐specified pathological criteria? Albeit low, based on the reaffirmed serious complication frequency reported in the study, the practitioner should be prepared to answer these questions before subjecting a patient to biopsy.…”