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Should we be doing routine biopsy after heart transplantation in a new era of anti-rejection?

Patel, Jignesh K; Kobashigawa, Jon A

Current Opinion in Cardiology: March 2006 - Volume 21 - Issue 2 - p 127–131
doi: 10.1097/01.hco.0000210309.71984.30
Heart transplantation

Purpose of review The endomyocardial biopsy has defined the diagnosis of rejection in cardiac transplantation and has historically been a vital tool when rejection rates following transplantation were high. Surveillance biopsies have been the cornerstone of post-transplant management, as signs or symptoms of rejection are non-specific. With significant improvements in immunosuppressive therapy, however, the incidence of clinically significant rejection has declined, bringing into question the need for routine surveillance biopsy. This article reviews the current role of the endomyocardial biopsy in the management of patients following cardiac transplantation.

Recent findings The endomyocardial biopsy is also limited by sub-optimal interobserver reproducibility, a lack of consensus with regard to treating certain grades of rejection, and often a lack of histological findings in patients with hemodynamic compromise, which frequently responds to anti-rejection therapy. Recent refinements, however, have allowed improved diagnosis of antibody mediated rejection, a relatively recently recognized entity. Moreover, a number of non-invasive modalities have been investigated recently as potential substitutes for the endomyocardial biopsy in detecting rejection.

Summary Despite the development of a variety of non-invasive methods for the detection of rejection, the endomyocardial biopsy will remain important in the management of patients following cardiac transplantation, as non-invasive techniques are associated with low specificity for the diagnosis of rejection. A new standardized classification will likely improve the utility of the biopsy by simplifying interpretation of cellular rejection and importantly allowing recognition of antibody-mediated rejection.

Division of Cardiology, The David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA

Correspondence to Jon A. Kobashigawa, MD, Division of Cardiology, The David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, #630, Los Angeles, California 90095, USA Tel: +1 310 794 1200; fax: +1 310 794 1211; e-mail:

© 2006 Lippincott Williams & Wilkins, Inc.