Cardiac transplantation has become the therapy of choice for the treatment
of end-stage congestive heart failure. One of the major problems after card
iac transplantation is acute cellular rejection. The diagnosis of rejection
is crucial to the management of transplant patients because rejection must
be successfully diagnosed and reversed. Endomyocardial biopsy is the major
method for detecting cardiac transplant rejection; however, this approach
is invasive and is associated with morbidity and mortality. One noninvasive
approach for detecting rejection is to monitor changes in the intramyocard
ial electrograms using pacemakers. Changes in the ventricular evoked respon
se amplitude (VERA) obtained during ventricular pacing have been correlated
with the presence of acute cellular rejection in both single center studie
s in Europe and a multicenter trial in five transplant centers in the Unite
d States. Given the high negative predictive value for the VERA, this appro
ach may provide a screen to determine if individual patients require more i
nvasive procedures such as endomyocardial biopsy and may aid in reducing th
e number of biopsies needed.