Zales V R, Crawford S, Backer C L, Pahl E, Webb C L, Lynch P, Mavroudis C, Benson D W
Division of Cardiology, Children's Memorial Hospital, Chicago, Illinois 60614.
J Am Coll Cardiol. 1994 Mar 1;23(3):766-71. doi: 10.1016/0735-1097(94)90766-8.
The aim of this study was to retrospectively evaluate the sensitivity of noninvasive surveillance (physical examination, echocardiography) of rejection in accurately predicting histologically documented rejection episodes. Additionally, the usefulness of routine scheduled biopsy and its safety in pediatric patients was explored.
Endomyocardial biopsy has been utilized as the standard for rejection surveillance after heart transplantation in adults, but its role in documenting clinically suspected rejection and in routine surveillance of pediatric patients has not been agreed upon.
Heart transplantation was performed in 14 neonates and 21 children. The immunosuppressive regimen consisted of cyclosporine, azathioprine and prednisone. All patients underwent routine noninvasive rejection surveillance that included clinical examination and echocardiography. In the neonates, biopsy was performed quarterly beginning 6 months after transplantation, after cessation of prednisone therapy. In the children, biopsy was performed 15 times in the 1st year. A minimum of five biopsy samples were interpreted using the Working Formulation for Heart Transplant Rejection.
In the neonates, 37 biopsies were performed. Evidence of rejection was present in only three biopsy samples obtained during eight episodes (38%) of clinically suspected rejection. In 29 biopsies performed when rejection was not clinically suspected, each biopsy was free of cellular infiltrate. In the children, 291 biopsies were performed. Evidence of rejection was present in only seven biopsies (41%) from 17 episodes of clinically suspected rejection. Cellular rejection was discovered during routine rejection surveillance biopsies in asymptomatic patients in 23 (8.4%) of 274 biopsies.
In neonates with clinically suspected rejection, endomyocardial biopsy identified which patients did not require rejection therapy. Endomyocardial biopsy surveillance did not detect any unsuspected cases of rejection. In children, noninvasive rejection surveillance was less reliable even in asymptomatic patients, suggesting that periodic endomyocardial biopsy should be utilized.
本研究旨在回顾性评估无创监测（体格检查、超声心动图）在准确预测经组织学证实的排斥反应发作方面的敏感性。此外，还探讨了常规定期活检在儿科患者中的实用性及其安全性。
心内膜心肌活检一直被用作成人心脏移植后排斥反应监测的标准，但对于其在记录临床疑似排斥反应以及儿科患者常规监测中的作用尚未达成共识。
对14例新生儿和21例儿童进行了心脏移植。免疫抑制方案包括环孢素、硫唑嘌呤和泼尼松。所有患者均接受常规无创排斥反应监测，包括临床检查和超声心动图。在新生儿中，移植后6个月开始，在泼尼松治疗停止后每季度进行一次活检。在儿童中，第一年进行了15次活检。使用心脏移植排斥反应工作分类法对至少五个活检样本进行解读。
在新生儿中，进行了37次活检。在8次临床疑似排斥反应发作期间获得的仅3个活检样本中存在排斥反应证据（38%）。在临床未怀疑有排斥反应时进行的29次活检中，每次活检均无细胞浸润。在儿童中，进行了291次活检。在17次临床疑似排斥反应发作中，仅7次活检（41%）存在排斥反应证据。在274次活检中的23次（8.4%）无症状患者的常规排斥反应监测活检中发现了细胞排斥反应。
在临床疑似排斥反应的新生儿中，心内膜心肌活检确定了哪些患者不需要进行排斥反应治疗。心内膜心肌活检监测未发现任何未被怀疑的排斥反应病例。在儿童中，即使是无症状患者，无创排斥反应监测也不太可靠，这表明应采用定期心内膜心肌活检。
