Current status of endomyocardial biopsy

Abstract

Endomyocardial biopsy (EMB) is widely used for surveillance of cardiac allograft rejection and for the diagnosis of unexplained ventricular dysfunction. Typically, EMB is performed through the jugular or femoral veins and is associated with a serious acute complication rate of less than 1% using current flexible bioptomes. Although it is accepted that EMB should be used to monitor for rejection after transplant, use of EMB for the diagnosis of various myocardial diseases is controversial. Diagnosis of myocardial disease in the nontransplant recipient is often successful via noninvasive investigations including laboratory evaluation; echocardiography, nuclear studies, and magnetic resonance imaging can yield specific diagnoses in the absence of invasive EMB. Therefore, use of the technique is patient specific and depends on the potential prognostic and treatment information gained by establishing a pathologic diagnosis beyond noninvasive testing.

FIGURE 1.

Commonly used bioptomes. A, Single-use 50-cm Novatome (Sholten Surgical Instruments, Inc, Lodi, CA) with a 2.3-mm tip that requires a 9-F sheath. B, Argon endomyocardial biopsy forceps (Argon Medical Devices, Inc, Athens, TX) with a 1.8-mm tip that requires a 6-F sheath or a 2.3-mm tip that requires a 7-F sheath. C, Bipal 7 bioptome, 50 cm and 104 cm (Cordis Corp, Miami Lakes, FL) with a 2.3-mm tip that requires a 7-F sheath. D, 8-F Transseptal Mullens (Medtronic, Inc, Minneapolis, MN) sheath when using the longer Bipal 7 bioptome through right femoral vein access to improve tip control and placement.

FIGURE 2.

Crush artifact, showing pinching of the sample at the time of procurement (arrows) (hematoxylin-eosin, original magnification, x40).

FIGURE 3.

Bayesian model for utility of endomyocardial biopsy in myocarditis. As with any diagnostic procedure, utility is maximized when the pretest probability of disease is intermediate. Ultimately, clinical and noninvasive parameters may supplant routine biopsy as the initial test and serve to categorize patients into low, medium, and high likelihood of rejection strata. Those with an intermediate likelihood of rejection stand to benefit most from a diagnostic biopsy. From Am Heart J, with permission from elsevier.

FIGURE 4.

Transesophageal echocardiographic images of right atrial mass in a 56-year-old man with small cell lung cancer. The mass was biopsied using a 9-F bioptome through the superior vena cava (SVC). Subsequent pathologic analysis revealed metastatic small cell carcinoma.