Elsevier

JACC: Heart Failure

Volume 11, Issue 3, March 2023, Pages 263-276
JACC: Heart Failure

State-of-the-Art Review
The End of Endomyocardial Biopsy?: A Practical Guide for Noninvasive Heart Transplant Rejection Surveillance

https://doi.org/10.1016/j.jchf.2022.11.002Get rights and content
Under an Elsevier user license
open archive

Highlights

  • Rejection surveillance using gene expression profiling and dd-cfDNA is noninferior to endomyocardial biopsy.

  • Transitioning away from traditional biopsy surveillance raises many practical questions.

  • In this paper, we provide guidance for the transition and early implementation process.

  • The clinical value of dd-cfDNA may offer benefits beyond current surveillance strategies, pending future prospective studies.

Abstract

Noninvasive heart transplant rejection surveillance using gene expression profiling (GEP) to monitor immune activation is widely used among heart transplant programs. With the new development of donor-derived cell-free DNA (dd-cfDNA) assays, more programs are transitioning to a predominantly noninvasive rejection surveillance protocol with a reduced frequency of endomyocardial biopsies. As a result, many practical questions arise that potentially delay implementation of these valuable new tools. The purpose of this review is to provide practical guidance for clinicians transitioning toward a less invasive acute rejection monitoring protocol after heart transplantation, and to answer 10 common questions about the GEP and dd-cfDNA assays. Evidence supporting GEP and dd-cfDNA testing is reviewed, as well as guidance on test interpretation and future directions.

Key Words

biomarker
biopsy
dd-cfDNA
gene expression profiling
heart transplant
rejection

Abbreviations and Acronyms

ACR
acute cellular rejection
AMR
antibody-mediated rejection
CAV
cardiac allograft vasculopathy
cfDNA
cell-free DNA
dd-cfDNA
donor-derived cell-free DNA
dnDSA
de novo donor-specific antibody
DSA
donor-specific antibody
EMB
endomyocardial biopsy
GEP
gene expression profiling
HT
heart transplantation
ISHLT
International Society of Heart and Lung Transplantation
LVEF
left ventricular ejection fraction

Cited by (0)

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.