Long-term follow-up of pediatric cardiac transplant recipients on a steroid-free regime: The role of endomyocardial biopsy

Background: Endomyocardial biopsy is used in long-term follow-up of cardiac transplant recipients to detect sub-clinical rejection. The value of this for adults and children on triple-drug immunosuppression has been disputed. We investigated its value in children maintained on a steroid-free regime. Methods: We used a retrospective review of annual surveillance biopsy resul ts from children younger than 13 years at the time of cardiac transplant. Results: In a series of 40 children older than 10 years, we found no eviden ce of rejection in 88/130 (67.7%) biopsies; 41/130 (31.5%) showed grade 1A rejection, and 1/130 (0.8%) showed grade 1B rejection. No grade 2, 3, or 4 biopsies were found. Nine patients with 1A rejection had subsequent grade 0 biopsies, without any adjustment in treatment. Seven children had treatmen t changes and repeat biopsies because of grade 1A biopsies. Conclusions: Significant late rejection is rare even in children on steroid -free maintenance. It is unlikely to be detected unexpectedly, and the prac tice of indefinite routine biopsy in children who are well is not justified . Future use should focus on individuals at higher risk of rejection.