Chapters Transcript Multiorgan Transplantation Course: Advanced Heart Failure Cases and Controversies How challenging is it with center variation uh with respect to, um, differences in biopsy or non-biopsy surveillance strategy to create a trial that would allow us to come at a consensus of how many biopsies is too little, how many years too much, and how is that going to improve? Yeah, I mean, I, I, I think that with our current registries, we're I think the performance test characteristics of these things are, are pretty established, um, so I think it don't really need a randomized trial. I think it depends on the sender and their willingness to sort of take risk or not, um, in terms of how they use these things, particularly in the setting of again sort of routine, um, rejection surveillance. I think with the more interesting trial is, and we've been trying to Karen and I have been trying to get this funded and find partners to do it, is to treat cell-free DNAs and not do biopsies. Um, and to really see if we can use that as a new gold standard, um, because as we've seen, you know, we see things that we call rejection and we treat as rejection, but may not actually be rejection based upon sort of what we see when we do self-free DNA's with them as well. So I, I think ultimately that's maybe the more interesting question is can we randomize people to a strategy of biopsy-based treatment versus self-free DNA based treatment. And you know, some of it also depends a little, I mean, the reality is, is that a lot of what's inhibited the uptake of these tests isn't people's. Reluctant to believe that they work, um, there's a huge financial piece to it, right? So that a lot of centers, a lot of the RVUs that you use to pay your heart failure doctors is generated in the in the lab, not so much through ENM coding, and so it's hard to take that away from the docs if the if the center is not gonna then Maintain their pay at what it was before. Uh, you know, one of the reasons why it was so easy to do at Stanford was one, cause we've been doing self-free DNA for forever, you know, Hanna and Kieran's work going back for years, so there wasn't any trepidation about whether or not it worked, but we didn't do any of the biopsies. So when we decided to just basically Almost not do any biopsies anymore. It wasn't any skin off our sort of financial teeth cause it it didn't impact us from an RVU standpoint and the cath lab guys like loved us because they didn't have to do the biopsies anymore, and they could do their complex cases. So my guess is uptake is probably more related to the financial piece, but I think moving forward, I think the interesting question is, is can we get away from biopsies is the arbiter of whether or not somebody is having rejection or not. Published May 10, 2024 Created by Related Presenters Alex Reyentovich, MD View full profile
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