Safety and utility of the routine surveillance biopsy in pediatric patients 2 years after heart transplantation

Objectives: The standard for diagnosing allograft rejection after heart tra nsplantation is the endomyocardial biopsy, but the value of routine surveil lance biopsies after 2 years after transplant is controversial. The objecti ve of this study was to determine the necessity and safety of surveillance biopsies and to correlate rejection with signs and symptoms beyond the seco nd post-transplant anniversary in pediatric patients. Study design: We reviewed the results of 899 biopsies and coincident clinic al histories in 56 pediatric patients, comprising 314 patient-years of foll owup. Patients were classified as having symptoms or not based on a blinded review of their clinical status and echocardiograms. Biopsies were classif ied as negative or positive with established criteria. Results: After biopsies performed less than 2 years after transplant or as a follow-up for a positive biopsy were excluded, 481 biopsies were availabl e for analysis, of which 20 (4%) were positive. Positive biopsies were foun d in 15 (3%) of 456 biopsies in patients without symptoms compared with 5 ( 20%) of 25 biopsies in patients with symptoms. Patients with symptoms were 6 times more likely to have a positive biopsy compared with patients withou t symptoms. Of the positive rejection episodes, 75% occurred in patients wi thout symptoms. Conclusion: Although rejection is uncommon in pediatric patients greater th an 2 years after transplant, episodes of treatable allograft rejection can occur in the absence of clinical signs and symptoms. This study emphasizes the safety of and the need to continue to perform routine surveillance biop sies in patients without symptoms, even after the second post-transplant ye ar.