One-year cutoff for biopsies after heart transplants saves $22.5M

Physicians monitoring heart transplant patients rely on frequent endomyocardial biopsies to detect nonsymptomatic rejection. But for how long? One year may be sufficient, a cost-effectiveness analysis concluded.

While options to detect and prevent rejection are changing, biopsies remain the gold standard. Physicians who order the tests still must weigh the benefits to the patient against risks and costs. A team led by Brent C. Lampert, DO, of The Ohio State University Wexner Medical Center in Columbus, used a model to explore several strategies for following up with heart transplant patients up to 36 months post-operation.

They found that ending endomyocardial biopsies after 12 months saved $2,884 per patient and gained the patient 0.0011 quality life years when annual risk for asymptomatic rejection was 2.5 percent. According to Lampert et al, this strategy would save $22.5 million annually in the U.S. against the current strategy of biopsies every six months for the subsequent five years post-transplant.

The next least costly strategy was reported to be every six months for year two post-transplant; however, the data on approximate costs and quality life years gained with a 2.5 percent risk of rejection were not made available.

However, when Lampert et al reviewed the data with an 8.5 percent risk for asymptomatic rejection, they found that the strategy of endomyocardial biopsy every six months for year two gained 0.0006 quality life years over the 12-month strategy but cost nearly $5 million per quality life year gained. This magnified cost for little benefit carried over in all strategies that utilized endomyocardial biopsies beyond 24 months.

Beyond cost-effectiveness, Lampert et al cited a need to reduce the actual procedural risks of using endomyocardial biopsy to detect asymptomatic rejection by reducing the number of biopsies a patient had to undergo. Complications they mentioned included cardiac tamponade, arrhythmias, severe tricuspid regurgitation, bleeding and accidental arterial puncture. These risks, weighed against the risk for rejection of the organ, have been part of earlier eras of less effective immunosuppression and were considered to be a justifiable risk against potential mortality.

Lampert et al recognized this strategy may not be sufficient to establish reduced risk in all patients and did not review newer methods for establishing patient’s rejection status. However, as endomyocardial biopsies are currently the most frequent method for assessing cardiac transplant patients, they wrote that use of this form of monitoring should be reassessed.

This study was published online Aug. 7 in Circulation: Heart Failure.