Utility of routine evaluations for rejection in patients greater than 2 years after heart transplantation

AIMS: 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. METHODS AND RESULTS: 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. CONCLUSIONS: Acute asymptomatic rejection is rare after the second post‐transplant year. Obtaining surveillance studies beyond the second post‐transplant year is not cost‐effective.