Limited diagnostic yield of endomyocardial biopsy after heart transplantation Endomyocardial biopsy (EMB) is the method of choice to assess the potential rejection episodes in post-transplant heart recipients [1]. Since it is an invasive procedure, it is associated with the risk of complications. Therefore, many attempts have been made to monitor the risk of potential rejection in a non-invasive manner. Among them, IMAGE and the CARGO gene-expression profiling protocols ultimately proved to be promising. Nevertheless, in most of the heart transplant centers across the world, EMB remained the gold standard to monitor rejection episodes. Moreover, the majority of the institutions developed local regimens of patient surveillance after heart transplantation (HTx). They can be divided into two main groups, depending on the general assumptions. The first is focused on the high number of EMBs performed according to a routine schedule (routine surveillance EMB – rsEMB), which in theory enables the diagnosis and treatment of acute cellular rejection (ACR) episodes before the development of clinical signs of rejection. The second concept focuses on clinical symptoms that are believed to trigger EMB, which is performed in case of ACR suspicion – clinically driven EMB (cdEMB). Since the diagnostic yield of rsEMB is limited, which means that the majority of the results are unable to prove rejection, it has been postulated to decrease the number of routinely performed EMBs [2]. Possible short- and long-term complications of EMB – from experimental to routine practice EMBs – were first performed by the Japanese cardiac surgeons Sakakibara and Konno in 1962, with the latter being considered the inventor of the method [3]. Likewise, EMB was introduced to clinical practice by Caves and colleagues in 1974 [4]. Interestingly, Japanese scientists made a significant contribution to the development and improvement of this technique. Nevertheless, due to medical–legislative reasons the national transplantation program in Japan for many years stayed below the national demands and possibilities. It should be emphasized that EMB, although widely characterized in the literature as a relatively safe technique with only a few unfavorable outcomes, may be associated with either acute or delayed complications – its frequency varies between 3% and 6% [5, 6]. Right ventricle perforation with the subsequent pericardial tamponade (0.5–2.6%) pneumothorax...
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