Golbus Jessica R, Konerman Matthew C, Aaronson Keith D
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
ESC Heart Fail. 2020 Aug;7(4):1809-1816. doi: 10.1002/ehf2.12745. Epub 2020 Jun 3.
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.
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.
Acute asymptomatic rejection is rare after the second post-transplant year. Obtaining surveillance studies beyond the second post-transplant year is not cost-effective.
指南支持心脏移植（HT）后至少5年进行常规排斥监测检测。对于HT术后超过2年的患者，我们研究了哪些临床特征可预测常规监测研究的持续情况、常规监测停止后的结局以及不同监测策略的成本效益。
我们回顾性确定了2007年至2016年在本中心接受首次HT且术后存活≥760天（n = 217）的18岁以上受试者。回顾了所有心内膜心肌活检（EMB）和基因表达谱（GEP）的临床背景，以确定研究是常规进行还是由临床状态变化触发。根据移植后第二年治疗心脏病专家继续常规研究的意图，将受试者分为基于检测的监测组（n = 159）或基于体征/症状的监测组（n = 53）。构建马尔可夫模型，将两种基于检测的监测策略与停止常规研究的基线策略进行比较。共进行了120项研究；835项为常规研究。99.0%的常规EMB和99.8%的常规GEP未出现显著排斥反应。治疗心脏病专家的执业年限、患者年龄和免疫抑制方案可预测监测策略。各组之间的结局无差异。常规监测EMB成本更高，且比2年后停止常规研究的策略效果略差；监测GEP的增量成本效益比为167万美元/质量调整生命年。
移植后第二年之后急性无症状排斥反应罕见。移植后第二年之后进行监测研究不具有成本效益。
