Myocarditis endomyocardial biopsy

Myocarditis Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology Adrenergic Myocarditis Giant Cell Myocarditis
Causes
Differentiating Myocarditis from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Myocarditis endomyocardial biopsy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Google Images
American Roentgen Ray Society Images of Myocarditis endomyocardial biopsy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Myocarditis endomyocardial biopsy
CDC on Myocarditis endomyocardial biopsy
Myocarditis endomyocardial biopsy in the news
Blogs on Myocarditis endomyocardial biopsy
Directions to Hospitals Treating Type page name here
Risk calculators and risk factors for Myocarditis endomyocardial biopsy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-In-Chief: Varun Kumar M.B.B.S., Maliha Shakil, M.D. [2]

Overview

Endomyocardial biopsy remains the gold standard test to evaluate for the presence of and to subclassify the type of myocarditis. A small tissue sample of the endocardium and myocardium is obtained via right sided cardiac catheterization. The sample is then evaluated by a pathologist using immunochemistry and special staining techniques as necessary. Histopathological features include abundant edema in the myocardial interstitium and an inflammatory infiltrate which is rich in lymphocytes and macrophages. Focal destruction of myocytes as a result of the inflammatory process results in left ventricular dysfunction. Endomyocardial biopsy is recommended when the results would identify an underlying disease that is amenable to therapy. Routine performance of endomyocardial biopsy is not recommended in all patients with myocarditis.

Endomyocardial Biopsy

• The Heart Failure Society of America recommends that performance of endomyocardial biopsy should be considered when cardiac function deteriorates acutely with an unknown etiology that is unresponsive to medical therapy (Strength of Evidence = B).

• Non-specific findings such as hypertrophy, cell loss, and fibrosis may be noted on biopsy. However, biopsy findings that significantly impact patient management have not been conclusively established. Although inflammatory changes in the myocardium may be detected in viral myocarditis, the majority of patients with biopsy proven myocarditis improve with supportive therapy alone without the need for antiviral or anti-inflammatory treatment. Endomyocardial biopsy has a low sensitivity and specificity which could be explained by the focal and transient nature of the inflammatory infiltrates.

Standardizing the Interpretation of Endomyocardial Biopsies: The Dallas Criteria

Histologically, both active inflammatory infiltrate within the myocardium and associated myocyte necrosis (the Dallas pathologic criteria) are present in myocarditis. Despite its limitations, the Dallas criteria have established uniform histologic criteria diagnosing myocarditis and have substantially reduced the variability in diagnosing the disease. Some of the criteria are as follows:

“

Active myocarditis: The presence of an inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes not typical of the ischaemic damage associated with coronary artery disease. Borderline myocarditis: The presence of an inflammatory infiltrate of the myocardium without necrosis or degeneration of adjacent myocytes.

”

Scenarios in Which Endomyocardial Biopsy May Be Useful

• Subacute or acute symptoms of heart failure refractory to standard management
• Rapid worsening of ejection fraction despite standard pharmacological therapy
• Development of cardiac arrhythmias such as ventricular tachycardia and/or heart block
• Heart failure with concomitant rash, fever, or peripheral eosinophilia
• Cardiac dysfunction thought to be secondary to the following conditions as the results of endomyocardial biopsy may alter the therapy:
  • Collagen vascular diseases:
    • Systemic lupus erythematosus
    • Scleroderma
    • Polyarteritis nodosum
  • Infiltrative diseases:
    • Amyloidosis: These patients are not eligible for cardiac transplantation.
    • Sarcoidosis
    • Hemachromatosis
  • Giant cell myocarditis: Myocardial biopsy may optimize the management of these patients by identifying patients who may benefit from early heart transplantation.

Complications of Endomyocardial Biopsy

• Complications may be as high as 6% as observed in a series where 546 patients with cardiomyopathy underwent right ventricular endomyocardial biopsy. Several other studies reported the incidence of complications to be 0.5 to 1.5%.

• Complications of endomyocardial biopsy include:

• Myocardial perforation leading to pericardial tamponade
• Heart block
• Pulmonary embolization
• Pneumothorax
• Nerve injury
• Hematoma
• Tricuspid valve damage
• Arteriovenous fistula
• Deep venous thrombosis
• Bleeding at the puncture site (venous/arterial due to accidental arterial puncture)
• Arrhythmias (supraventricular tachycardia/ventricular tachycardia/complete heart block)
• Tricuspid valve damage
• Coronary artery to right ventricle fistula

2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT)

Endomyocardial Biopsy in Patients Presenting With Heart Failure (DO NOT EDIT)

Class III (No Benefit)

" 1. Endomyocardial biopsy should not be performed in the routine evaluation of patients with heart failure. (Level of Evidence: C) "

Class IIa

"1. Endomyocardial biopsy can be useful in patients presenting with heart failure when a specific diagnosis is suspected that would influence therapy. (Level of Evidence: C) "

2007 AHA/ACCF/ESC Scientific Statement: The Role of Endomyocardial Biopsy (EMB) in Fourteen Clinical Scenarios

Class I

"1. EMB should be performed in the setting of unexplained, new-onset heart failure of less than 2 weeks’ duration associated with a normal-sized or dilated left ventricle and hemodynamic compromise. (Level of Evidence: B) "

"2. EMB should be performed in the setting of unexplained, new-onset heart failure of 2 weeks’ to 3 months’ duration associated with a dilated left ventricle and new ventricular arrhythmias, second- or third-degree heart block, or failure to respond to usual care within 1 to 2 weeks. (Level of Evidence: B) "

Class III (No Benefit)

"1. EMB should not be performed in the setting of unexplained atrial fibrillation. (Level of Evidence: C) "

Class IIa

"1. EMB is reasonable in the clinical setting of unexplained heart failure of more than 3 months’ duration associated with a dilated left ventricle and new ventricular arrhythmias, second- or third-degree heart block, or failure to respond to usual care within 1 to 2 weeks. (Level of Evidence: C) "

"2. EMB is reasonable in the setting of unexplained heart failure associated with a dilated cardiomyopathy (DCM) of any duration associated with suspected allergic reaction and/or eosinophilia. (Level of Evidence: C) "

"3. EMB is reasonable in the setting of unexplained heart failure associated with suspected anthracycline cardiomyopathy. (Level of Evidence: C) "

"4. EMB is reasonable in the setting of heart failure associated with unexplained restrictive cardiomyopathy. (Level of Evidence: C) "

"5. EMB is reasonable in the setting of suspected cardiac tumors. (Level of Evidence: C) "

"6. EMB is reasonable in the setting of unexplained cardiomyopathy in children. (Level of Evidence: C) "

Class IIb

"1. EMB may be considered in the setting of unexplained, new-onset heart failure of 2 weeks’ to 3 months’ duration associated with a dilated left ventricle, without new ventricular arrhythmias or second- or third-degree heart block, that responds to usual care within 1 to 2 weeks. (Level of Evidence: B) "

"2. EMB may be considered in the setting of unexplained heart failure of more than 3 months’ duration associated with a dilated left ventricle, without new ventricular arrhythmias or second- or third-degree heart block, that responds to usual care within 1 to 2 weeks. (Level of Evidence: C) "

"3. EMB may be considered in the setting of heart failure associated with unexplained hypertrophic cardiomyopathy (HCM). (Level of Evidence: C) "

"4. EMB may be considered in the setting of suspected arrhythmogenic right ventricular dysplasia (ARVD/C). (Level of Evidence: C) "

"5. EMB may be considered in the setting of unexplained unexplained ventricular arrhythmias. (Level of Evidence: C) "