Stehlik J, Starling R C, Movsesian M A, Fang J C, Brown R N, Hess M L, Lewis N P, Kirklin J K
Cardiology Section, University of Utah School of Medicine, VA Salt Lake City Health Care System, Salt Lake City, Utah 84148, USA.
J Heart Lung Transplant. 2006 Dec;25(12):1402-9. doi: 10.1016/j.healun.2006.10.003.
The utility of long-term endomyocardial biopsy surveillance in heart transplant recipients has been questioned. This study was undertaken to identify risk factors for late rejection and to examine the impact of different biopsy surveillance protocols on outcomes using the registry of the Cardiac Transplant Research Database.
The study group consisted of all adult patients who underwent heart transplantation at the 33 centers participating in this investigation between January 1, 1993 and January 1, 2002, survived past the second post-transplant year, and were followed-up by a defined surveillance biopsy protocol.
During a follow-up that consisted of 24,137 patient-years, 1,626 late rejections occurred. Shorter time since transplant, history of rejection, younger age and African-American ethnicity of the recipient were strong risk factors for late rejection. The practice of surveillance biopsy varied among institutions. Continued surveillance increased the rate of diagnosis of late rejection (RR = 1.3, p = 0.002). There was no reduction in the incidence of hemodynamically compromising rejection and no increase in survival in patients with long-term vs intermediate-term surveillance. Short-term surveillance was associated with an increased incidence of hemodynamically compromising rejection, particularly among high-risk patients, and increased mortality in African-American patients.
There are no apparent benefits from surveillance biopsy beyond 5 years post-transplant. Surveillance biopsy between 2 and 5 years post-transplant was found to reduce mortality in African-American recipients. Non-African-American recipients at high risk for late rejection will likely benefit from surveillance up to 5 years post-transplant.
心脏移植受者长期心内膜心肌活检监测的实用性受到质疑。本研究旨在利用心脏移植研究数据库登记处确定晚期排斥反应的危险因素，并研究不同活检监测方案对预后的影响。
研究组包括1993年1月1日至2002年1月1日期间在参与本调查的33个中心接受心脏移植、移植后存活超过第二年并按照确定的监测活检方案进行随访的所有成年患者。
在为期24137患者年的随访期间，发生了1626次晚期排斥反应。移植后时间较短、有排斥反应史、受者年龄较小和非裔美国人种族是晚期排斥反应的强烈危险因素。各机构的监测活检做法各不相同。持续监测增加了晚期排斥反应的诊断率（相对风险=1.3，p=0.002）。长期监测与中期监测相比，血流动力学受损排斥反应的发生率没有降低，生存率也没有提高。短期监测与血流动力学受损排斥反应的发生率增加有关，尤其是在高危患者中，并且非裔美国患者的死亡率增加。
移植后5年以上进行监测活检没有明显益处。发现移植后2至5年进行监测活检可降低非裔美国受者的死亡率。晚期排斥反应高危的非非裔美国受者可能从移植后长达5年的监测中获益。
