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Cusi V, Vaida F, Wettersten N, Rodgers N, Tada Y, Gerding B, Urey MA, Greenberg B, Adler ED, Kim PJ. Incidence of Acute Rejection Compared With Endomyocardial Biopsy Complications for Heart Transplant Patients in the Contemporary Era. Transplantation 2024; 108:1220-1227. [PMID: 38098137 DOI: 10.1097/tp.0000000000004882] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND The reference standard of detecting acute rejection (AR) in adult heart transplant (HTx) patients is an endomyocardial biopsy (EMB). The majority of EMBs are performed in asymptomatic patients. However, the incidence of treated AR compared with EMB complications has not been compared in the contemporary era (2010-current). METHODS The authors retrospectively analyzed 2769 EMBs obtained in 326 consecutive HTx patients between August 2019 and August 2022. Variables included surveillance versus for-cause indication, recipient and donor characteristics, EMB procedural data and pathological grades, treatment for AR, and clinical outcomes. RESULTS The overall EMB complications rate was 1.6%. EMBs performed within 1 mo after HTx compared with after 1 mo from HTx showed significantly increased complications (OR, 12.74, P < 0.001). The treated AR rate was 14.2% in the for-cause EMBs and 1.2% in the surveillance EMBs. We found the incidence of AR versus EMB complications was significantly lower in the surveillance compared with the for-cause EMB group (OR, 0.05, P < 0.001). We also found the incidence of EMB complications was higher than treated AR in surveillance EMBs. CONCLUSIONS The yield of surveillance EMBs has declined in the contemporary era, with a higher incidence of EMB complications compared with detected AR. The risk of EMB complications was highest within 1 mo after HTx. Surveillance EMB protocols in the contemporary era may need to be reevaluated.
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Affiliation(s)
| | - Florin Vaida
- Department of Family Medicine and Public Health, UC San Diego, La Jolla, CA
| | - Nicholas Wettersten
- Cardiology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
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Cusi V, Vaida F, Wettersten N, Rodgers N, Tada Y, Gerding B, Greenberg B, Urey MA, Adler E, Kim PJ. Benefit versus Risk of Endomyocardial Biopsy for Heart Transplant Patients in the Contemporary Era. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.19.23290196. [PMID: 37293037 PMCID: PMC10246074 DOI: 10.1101/2023.05.19.23290196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background The reference standard of detecting acute rejection (AR) in adult heart transplant (HTx) patients is an endomyocardial biopsy (EMB). The majority of EMBs are performed in asymptomatic patients. However, the benefit of diagnosing and treating AR compared to the risk of EMB complications has not been compared in the contemporary era (2010-current). Methods The authors retrospectively analyzed 2,769 EMB obtained in 326 consecutive HTx patients between August 2019 and August 2022. Variables included surveillance versus for cause indication, recipient and donor characteristics, EMB procedural data and pathologic grades, treatment for AR, and clinical outcomes. Results The overall EMB complication rate was 1.6%. EMBs performed within 1 month after HTx compared to after 1 month from HTx showed significantly increased complications (OR = 12.74, p < 0.001). The treated AR rate was 14.2% in the for cause EMBs and 1.2% in the surveillance EMBs. We found the benefit/risk ratio was significantly lower in the surveillance compared to the for cause EMB group (OR = 0.05, p < 0.001). We also found the benefit to be lower than risk in surveillance EMBs. Conclusions The yield of surveillance EMBs has declined, while for cause EMBs continued to demonstrate a high benefit/risk ratio. The risk of EMB complications was highest within 1 month after HTx. Surveillance EMB protocols in the contemporary era may need to be re-evaluated.
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Just IA, Guelfirat M, Leser L, Uecertas A, Kopp Fernandes L, Godde M, Merke N, Stawowy P, Hennig F, Knosalla C, Falk V, Knierim J, Schoenrath F. Diagnostic and Prognostic Value of a TDI-Derived Systolic Wall Motion Analysis as a Screening Modality for Allograft Rejection after Heart Transplantation. Life (Basel) 2021; 11:life11111206. [PMID: 34833082 PMCID: PMC8622239 DOI: 10.3390/life11111206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Despite the risk for complications, allograft surveillance after orthotopic heart transplantation (OHT) is performed by cardiac catheterization and biopsies. We investigated the diagnostic and prognostic value of a TDI-derived systolic wall motion analysis of the posterobasal wall of the left ventricle (Sm) as a screening modality in OHT aftercare. Methods: We examined data of 210 eligible patients who underwent OHT between 2010 and 2020. Forty-four patients who had died within the initial hospital stay were excluded. For 166 patients, baseline and follow-up data were analyzed. The mean age at OHT was 46.2 (±11.4) years; 76.5% were male. Results: Within the observational period, 22 (13.3%) patients died. In total, 170 episodes of acute cellular or humoral rejections occurred (84 ISHLT1R; 13 ISHLT2R; 8 ISHLT3R; 65 AMR), and 29 catheterizations revealed cardiac allograft vasculopathy (5 CAV1; 4 CAV2; 20 CAV3). Individual Sm radial/longitudinal remained stable within the follow-up period (11.5 ± 2.2 cm/s; 10.9 ± 2.1 cm/s). Patients with acute rejections and CAV3 showed significant Sm radial/longitudinal reductions (AMR1: 1.6 ± 1.9 cm/s, confidence interval (CI) 0.77–0.243, p < 0.001; 1.8 ± 2.0 cm/s, CI 0.92–0.267, p < 0.001. ISHLT1R: 1.7 ± 1.8 cm/s, CI 1.32–2.08, p < 0.001; 2.0 ± 1.6 cm/s, CI 1.66–2.34, p < 0.001. CAV3: 1.3 ± 2.5 cm/s, CI 0.23–2.43, p < 0.017; 1.4 ± 2.8 cm/s, CI 0.21–2.66, p < 0.021). Lower Sm was associated with a threefold increase in all-cause mortality (hazard ratio (HR) 3.24, CI 1.2–8.76, p = 0.020; HR 2.92, CI 1.19–7.18, p = 0.019). Overall, Sm-triggered surveillance led to 0.75 invasive diagnostics per patient post-OHT year. Conclusions: Sm remained stable in the post-OHT course. Reductions indicated ISHLT1R, AMR1 and CAV3 and were associated with higher all-cause mortality. Sm-triggered surveillance may be referred to as a safe, high-yield screening modality in OHT aftercare.
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Affiliation(s)
- Isabell A. Just
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
- Correspondence:
| | - Meryem Guelfirat
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Laura Leser
- Department of Anesthesiology, German Heart Center Berlin, 13353 Berlin, Germany;
| | - Ata Uecertas
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Laurenz Kopp Fernandes
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Maren Godde
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Nicolas Merke
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Philipp Stawowy
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
- Department of Cardiology and Internal Medicine, German Heart Center Berlin, 13353 Berlin, Germany
| | - Felix Hennig
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
- Department of Cardiothorarcic Surgery, Charité, Corpoate Member of Freie Universität Berlin, Humboldt-Universitüt Berlin and Berlin Institute of Health, 13353 Berlin, Germany
- Translational Cardiovascular Technologies, Department of Health Sciences, Eidgenoessische Technische Hochschule (ETH) Zurich, 8092 Zurich, Switzerland
| | - Jan Knierim
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
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Bracamonte-Baran W, Gilotra NA, Won T, Rodriguez KM, Talor MV, Oh BC, Griffin J, Wittstein I, Sharma K, Skinner J, Johns RA, Russell SD, Anders RA, Zhu Q, Halushka MK, Brandacher G, Čiháková D. Endothelial Stromal PD-L1 (Programmed Death Ligand 1) Modulates CD8 + T-Cell Infiltration After Heart Transplantation. Circ Heart Fail 2021; 14:e007982. [PMID: 34555935 PMCID: PMC8550427 DOI: 10.1161/circheartfailure.120.007982] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The role of checkpoint axes in transplantation has been partially addressed in animal models but not in humans. Occurrence of fulminant myocarditis with allorejection-like immunologic features in patients under anti-PD1 (programmed death cell protein 1) treatment suggests a key role of the PD1/PD-L1 (programmed death ligand 1) axis in cardiac immune homeostasis. METHODS We cross-sectionally studied 23 heart transplant patients undergoing surveillance endomyocardial biopsy. Endomyocardial tissue and peripheral blood mononuclear cells were analyzed by flow cytometry. Multivariate logistic regression analyses including demographic, clinical, and hemodynamic parameters were performed. Murine models were used to evaluate the impact of PD-L1 endothelial graft expression in allorejection. RESULTS We found that myeloid cells dominate the composition of the graft leukocyte compartment in most patients, with variable T-cell frequencies. The CD (cluster of differentiation) 4:CD8 T-cell ratios were between 0 and 1.5. The proportion of PD-L1 expressing cells in graft endothelial cells, fibroblasts, and myeloid leukocytes ranged from negligible up to 60%. We found a significant inverse logarithmic correlation between the proportion of PD-L1+HLA (human leukocyte antigen)-DR+ endothelial cells and CD8+ T cells (slope, -18.3 [95% CI, -35.3 to -1.3]; P=0.030). PD-L1 expression and leukocyte patterns were independent of demographic, clinical, and hemodynamic parameters. We confirmed the importance of endothelial PD-L1 expression in a murine allogeneic heart transplantation model, in which Tie2Crepdl1fl/fl grafts lacking PD-L1 in endothelial cells were rejected significantly faster than controls. CONCLUSIONS Loss of graft endothelial PD-L1 expression may play a role in regulating CD8+ T-cell infiltration in human heart transplantation. Murine model results suggest that loss of graft endothelial PD-L1 may facilitate alloresponses and rejection.
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Affiliation(s)
- William Bracamonte-Baran
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
- Department of Medicine, Texas Tech University Health Sciences Center – Permian Basin, Odessa, TX, 79763, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Taejoon Won
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Katrina M Rodriguez
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Monica V Talor
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Byoung C Oh
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Jan Griffin
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
- Current Address: Department of Medicine, Columbia University, New York, NY
| | - Ilan Wittstein
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - John Skinner
- Department of Anesthesiology and Critical Care Medicine, Division of Adult Anesthesia, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Roger A Johns
- Department of Anesthesiology and Critical Care Medicine, Division of Adult Anesthesia, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Stuart D Russell
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
- Current Address: Department of Medicine, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Robert A Anders
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Qingfeng Zhu
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Marc K Halushka
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Daniela Čiháková
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
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5
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Seferović PM, Tsutsui H, McNamara DM, Ristić AD, Basso C, Bozkurt B, Cooper LT, Filippatos G, Ide T, Inomata T, Klingel K, Linhart A, Lyon AR, Mehra MR, Polovina M, Milinković I, Nakamura K, Anker SD, Veljić I, Ohtani T, Okumura T, Thum T, Tschöpe C, Rosano G, Coats AJS, Starling RC. Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy. Eur J Heart Fail 2021; 23:854-871. [PMID: 34010472 DOI: 10.1002/ejhf.2190] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 12/17/2022] Open
Abstract
Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant (HTx) rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples have significantly improved diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (i) an overview of the practical approach to EMB, (ii) an update on indications for EMB, (iii) a revised plan for HTx rejection surveillance, (iv) the impact of multimodality imaging on EMB, and (v) the current clinical practice in the worldwide use of EMB.
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Affiliation(s)
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Dennis M McNamara
- Heart and Vascur Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arsen D Ristić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Gerasimos Filippatos
- Attikon University Hospital, Department of Cardiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Karin Klingel
- Cardiopathology, Institute for Pathology, University Hospital, Tuebingen, Germany
| | - Aleš Linhart
- Department of Cardiovascular Medicine, Charles University, Prague, Czech Republic
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK
| | - Mandeep R Mehra
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marija Polovina
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Milinković
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin, Berlin, Germany
| | - Ivana Veljić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany.,Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Carsten Tschöpe
- Berlin Institute of Health (BIH) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Department of Cardiology, Campus Virchow Klinikum, Charite University, Berlin, Germany
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Rome, Italy.,Cardiology Clinical Academic Group, St George's Hospitals NHS Trust, London, UK
| | - Andrew J S Coats
- Monash University, Melbourne, Australia.,University of Warwick, Coventry, UK
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6
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Seferović PM, Tsutsui H, Mcnamara DM, Ristić AD, Basso C, Bozkurt B, Cooper LT, Filippatos G, Ide T, Inomata T, Klingel K, Linhart A, Lyon AR, Mehra MR, Polovina M, Milinković I, Nakamura K, Anker SD, Veljić I, Ohtani T, Okumura T, Thum T, Tschöpe C, Rosano G, Coats AJS, Starling RC. Heart Failure Association, Heart Failure Society of America, and Japanese Heart Failure Society Position Statement on Endomyocardial Biopsy. J Card Fail 2021; 27:727-743. [PMID: 34022400 DOI: 10.1016/j.cardfail.2021.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumors. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples has significantly improved the diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (1) an overview of the practical approach to EMB, (2) an update on indications for EMB, (3) a revised plan for heart transplant rejection surveillance, (4) the impact of multimodality imaging on EMB, and (5) the current clinical practice in the worldwide use of EMB.
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Affiliation(s)
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Dennis M Mcnamara
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arsen D Ristić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - Gerasimos Filippatos
- Attikon University Hospital, Department of Cardiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Karin Klingel
- Cardiopathology, Institute for Pathology, University Hospital, Tuebingen, Germany
| | - Aleš Linhart
- Department of Cardiovascular Medicine, Charles University, Prague, Czech Republic
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK
| | - Mandeep R Mehra
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marija Polovina
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Milinković
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Ivana Veljić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany; Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Carsten Tschöpe
- Berlin Institute of Health (BIH) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Department of Cardiology, Campus Virchow Klinikum, Charite University, Berlin, Germany
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Rome, Italy, and Cardiology Clinical Academic Group, St George's Hospitals NHS Trust
| | - Andrew J S Coats
- Monash University, Australia, and University of Warwick, Coventry, UK
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7
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Oh KT, Mustehsan MH, Goldstein DJ, Saeed O, Jorde UP, Patel SR. Protocol endomyocardial biopsy beyond 6 months-It is time to move on. Am J Transplant 2021; 21:825-829. [PMID: 32515104 DOI: 10.1111/ajt.16128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 01/25/2023]
Abstract
The optimal duration and frequency of routine surveillance endomyocardial biopsy (EMB) have been questioned in the current era of heart transplantation (HT), where the advances in immunosuppression and donor selection strategies have led to a decline in acute allograft rejection. We investigated the utility of routine EMB beyond 6 months post-HT. A single-center retrospective review was performed on 2963 EMBs from 220 HT recipients over 10 years. Each EMB was categorized into protocol or symptom-triggered biopsy and reviewed for rejection. Heart transplant recipients with ≥2 known risk factors for rejection were designated as an elevated risk group. The majority of rejections occurred within 3 months following HT. The yield of routine protocol EMBs was significantly lower than symptom-triggered EMBs, not only during the first 6 months post-HT (1.6% vs. 33.3%, P < .0001), but more so during the 6-12 months (0.1% vs 83.0%, P < .0001). A similar pattern was observed in heart transplant recipients at both elevated and standard risk for rejection. In conclusion, EMB was found to be a low-yield screening modality for rejection beyond 6 months post-HT.
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Affiliation(s)
- Kyung T Oh
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Cardiology, Bronx, NY, USA
| | - Mohammed H Mustehsan
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Cardiology, Bronx, NY, USA
| | - Daniel J Goldstein
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Cardiovascular and Thoracic Surgery, Bronx, NY, USA
| | - Omar Saeed
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Cardiology, Bronx, NY, USA
| | - Ulrich P Jorde
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Cardiology, Bronx, NY, USA
| | - Snehal R Patel
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Cardiology, Bronx, NY, USA
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8
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Sinphurmsukskul S, Ariyachaipanich A, Siwamogsatham S, Thammanatsakul K, Puwanant S, Benjacholamas V, Ongcharit P. Endomyocardial Biopsy and Prevalence of Acute Cellular Rejection in Heart Transplantation. Transplant Proc 2020; 53:318-323. [PMID: 33041079 DOI: 10.1016/j.transproceed.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/29/2020] [Accepted: 08/12/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Percutaneous endomyocardial biopsy (EMB) remains the criterion standard method for surveillance of allograft rejection after heart transplant (HT). However, data regarding utility of EMBs and prevalence of acute cellular rejection (ACR) in Asian populations are still limited. We aimed to report our experience in the use of EMBs and prevalence of ACR in HT recipients. METHODS We retrospectively evaluated all EMBs from consecutive HT recipients between January 2008 and December 2018. EMB pathology results were according to International Society for Heart and Lung Transplantation 2004 revision of biopsy grading. We also divided patients into previous era and current era group (underwent HT before and after 2015) to compare prevalence of ACR and survival outcome. RESULTS A total of 832 EMBs from 81 HT recipients were included. Pathologic reports revealed ACR grade 1R 22.8%, 2R 4.2%, and 3R 0.6%. At patient level, at least 1 episode of ACR grade 1R, 2R, and 3R were found in 70.6%, 24.7%, and 3.5% of the patients, respectively. When compared between era, frequency of EMB during the first year after HT in current era was significantly higher (9.74 ± 3.38 vs 4.93 ± 3.29, P < .001), but lower frequency of rejection grade ≥ 2R were found (2.3% vs 8.1%, P < .001). However, 1-year survival was not statistically different (76% in previous era vs 80% in current era, P = .37). CONCLUSIONS From our study, prevalence of grade ≥ 2R rejection was approximately 5%, which is comparable with previous studies. Further studies are needed to evaluate proper interval and number of EMBs in HT recipients.
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Affiliation(s)
- Supanee Sinphurmsukskul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - Aekarach Ariyachaipanich
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sarawut Siwamogsatham
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanokwan Thammanatsakul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sarinya Puwanant
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vichai Benjacholamas
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Pathum Wan, Bangkok, Thailand
| | - Pat Ongcharit
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Pathum Wan, Bangkok, Thailand
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9
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Non-invasive cardiac allograft rejection surveillance: reliability and clinical value for prevention of heart failure. Heart Fail Rev 2020; 26:319-336. [PMID: 32889634 DOI: 10.1007/s10741-020-10023-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 01/04/2023]
Abstract
Allograft rejection-related acute and chronic heart failure (HF) is a major cause of death in heart transplant recipients. Given the deleterious impact of late recognized acute rejection (AR) or non-recognized asymptomatic antibody-mediated rejection on short- and long-term allograft function improvement of AR surveillance and optimization of action strategies for confirmed AR can prevent AR-related allograft failure and delay the development of cardiac allograft vasculopathy, which is the major cause for HF after the first posttransplant year. Routine non-invasive monitoring of cardiac function can improve both detection and functional severity grading of AR. It can also be helpful in guiding the anti-AR therapy and timing of routine surveillance endomyocardial biopsies (EMBs). The combined use of EMBs with non-invasive technologies and methods, which allow detection of subclinical alterations in myocardial function (e.g., tissue Doppler imaging and speckle-tracking echocardiography), reveal alloimmune activation (e.g., screening of complement-activating donor-specific antibodies and circulating donor-derived cell-free DNA) and help in predicting the imminent risk of immune-mediated injury (e.g., gene expression profiling, screening of non-HLA antibodies, and circulating donor-derived cell-free DNA), can ensure the best possible surveillance and management of AR. This article gives an overview of the current knowledge about the reliability and clinical value of non-invasive cardiac allograft AR surveillance. Particular attention is focused on the potential usefulness of non-invasive tools and techniques for detection and functional grading of early and late ARs in asymptomatic patients. Overall, the review aimed to provide a theoretical and practical basis for those engaged in this particularly demanding up-to-date topic.
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10
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Golbus JR, Konerman MC, Aaronson KD. Utility of routine evaluations for rejection in patients greater than 2 years after heart transplantation. ESC Heart Fail 2020; 7:1809-1816. [PMID: 32489007 PMCID: PMC7373902 DOI: 10.1002/ehf2.12745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/26/2020] [Accepted: 04/21/2020] [Indexed: 11/09/2022] Open
Abstract
AIMS Guidelines support routine surveillance testing for rejection for at least 5 years after heart transplant (HT). In patients greater than 2 years post-HT, we examined which clinical characteristics predict continuation of routine surveillance studies, outcomes following discontinuation of routine surveillance, and the cost-effectiveness of different surveillance strategies. METHODS AND RESULTS We retrospectively identified subjects older than 18 who underwent a first HT at our centre from 2007 to 2016 and who survived ≥760 days (n = 217) post-HT. The clinical context surrounding all endomyocardial biopsies (EMBs) and gene expression profiles (GEPs) was reviewed to determine if studies were performed routinely or were triggered by a change in clinical status. Subjects were categorized as following a test-based surveillance (n = 159) or a signs/symptoms surveillance (n = 53) strategy based on treating cardiologist intent to continue routine studies after the second post-transplant year. A Markov model was constructed to compare two test-based surveillance strategies to a baseline strategy of discontinuing routine studies. One thousand twenty studies were performed; 835 were routine. Significant rejection was absent in 99.0% of routine EMBs and 99.8% of routine GEPs. The treating cardiologist's practice duration, patient age, and immunosuppressive regimen predicted surveillance strategy. There were no differences in outcomes between groups. Routine surveillance EMBs cost more and were marginally less effective than a strategy of discontinuing routine studies after 2 years; surveillance GEPs had an incremental cost-effectiveness ratio of $1.67 million/quality-adjusted life-year. CONCLUSIONS Acute asymptomatic rejection is rare after the second post-transplant year. Obtaining surveillance studies beyond the second post-transplant year is not cost-effective.
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Affiliation(s)
- Jessica R Golbus
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Matthew C Konerman
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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11
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Dandel M, Hetzer R. Impact of rejection-related immune responses on the initiation and progression of cardiac allograft vasculopathy. Am Heart J 2020; 222:46-63. [PMID: 32018202 DOI: 10.1016/j.ahj.2019.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/22/2019] [Indexed: 12/17/2022]
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12
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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.
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Kim JH, Oh J, Kim MJ, Kim IC, Uhm JS, Pak HN, Kang SM. Association of Newly Developed Right Bundle Branch Block with Graft Rejection Following Heart Transplantation. Yonsei Med J 2019; 60:423-428. [PMID: 31016903 PMCID: PMC6479131 DOI: 10.3349/ymj.2019.60.5.423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/16/2019] [Accepted: 03/13/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We aimed to examine associations between right bundle branch block (RBBB) following heart transplantation (HT) and graft rejection. MATERIALS AND METHODS We investigated 51 patients who underwent endomyocardial biopsies, electrocardiogram, right-side cardiac catheterization, and echocardiography at 1 month and 1 year after HT. We classified patients into four groups according to the development of RBBB, based on electrocardiogram at 1 month and 1 year: 1) sustained RBBB, 2) disappeared RBBB, 3) newly developed RBBB, and 4) sustained non-RBBB. The RBBB was defined as an RSR' pattern in V1 with a QRS duration ≥100 ms on electrocardiogram. RESULTS The newly developed RBBB group (n=13, 25.5%) had a higher rate of new onset graft rejection (from grade 0 to grade ≥1R, 30.8% vs. 10.0% vs. 21.4%, p=0.042) at 1 year, compared with sustained RBBB (n=10, 19.6%) and sustained non-RBBB group (n=28, 54.9%). In contrast, the incidence of resolved graft rejection (from grade ≥1R to grade 0) was higher in the sustained RBBB group than the newly developed RBBB and sustained non-RBBB groups (70.0% vs. 7.7% vs. 25.0%, p=0.042). Left atrial volume index was significantly higher in the newly developed RBBB group than the sustained RBBB and sustained non-RBBB groups (60.6±25.9 mL/m² vs. 36.0±11.0 mL/m² vs. 38.4±18.1 mL/m², p=0.003). CONCLUSION Close monitoring for new development of RBBB at 1 year after HT, which was associated with a higher incidence of new onset graft rejection, may be helpful to identify high risk patients for graft rejection.
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Affiliation(s)
- Jin Ho Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Departement of Cardiology, Konkuk University School of Medicine, Chungju, Korea
| | - Jaewon Oh
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Min Ji Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - In Cheol Kim
- Departement of Cardiology, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Sun Uhm
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hui Nam Pak
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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