The End of Endomyocardial Biopsy?: A Practical Guide for Noninvasive Heart Transplant Rejection Surveillance

JACC Heart Fail. 2023 Mar;11(3):263-276. doi: 10.1016/j.jchf.2022.11.002. Epub 2023 Jan 11.


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.

Keywords: biomarker; biopsy; dd-cfDNA; gene expression profiling; heart transplant; rejection.

Publication types

  • Review

MeSH terms

  • Biopsy
  • Cell-Free Nucleic Acids* / genetics
  • Graft Rejection / diagnosis
  • Heart Failure*
  • Heart Transplantation*
  • Humans
  • Postoperative Complications
  • Tissue Donors


  • Cell-Free Nucleic Acids