Endomyocardial biopsy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
An endomyocardial biopsy is an invasive heart procedure that is performed to obtain a small piece of myocardial tissue for pathologic evaluation.
Disease States that can be Diagnosed Using Endomyocardial Biopsy
The Biopsy Procedure
The procedure can be performed either from the neck (using the jugular vein), or from the femoral vein.
Approach from the neck
- Jugular vein approach (especially right internal jugular vein). Endomyocardial biopsy is performed in a supine position with local anesthesia.
- Subclavian vein approach is not preferable for a variety of reasons as: local anesthesia is less effective, because of the clavicle, the risk of pneumothorax is significantly higher as compared to puncture of the internal jugular vein and due to the anatomical course of the great veins, direction of the bioptome is more difficult.
Approach from the femoral vein
Evaluation of Biopsy Specimen
Biopsy specimens are prepared for light microscopy by hematoxiline – eosine staining.
Grading of Rejection
Morphologically, acute rejection is a mononuclear inflammatory reaction of predominantly lymphocytes against the myocardium. Grading of rejection is performed according to the guidelines of the International Society for Heart and Lung Transplantation (ISHLT) as follows:
- Grade 0: no evidence of rejection
- Grade Ia: focal perivascular or interstitial infiltrate without myocardial injury
- Grade Ib: multifocal or diffuse sparse infiltrate without myocardial injury
- Grade II: single focus or dense infiltrate with myocyte injury
- Grade IIIa: multifocal dense infiltrates with myocyte injury
- Grade IIIb: diffuse, dense infiltrates with myocyte injury
- Grade IV: diffuse and extensive polymorphous infiltrate with myocyte injury; may have hemorrhage, edema, and microvascular injury
Categories of cellular rejection
- Grade 0 R: no rejection
- Grade 1 R: mild rejection (Grades I A, I B and II)
- Grade 2 R: moderate rejection (Grade III A)
- Grade 3 R: severe rejection (Grade III B and IV)
Complications of Endomyocardial Biopsy[1][2]
Complications may be as high as 6% as observed in a series where 546 patients with cardiomyopathy underwent right ventricular endomyocardial biopsy[3]. Several other studies reported the incidence of complications to be 0.5 to 1.5%[2][4].
- 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)
- Perforation/pericardial tamponade
- Arrhythmias (supraventricular tachycardia/ventricular tachycardia/complete heart block)
- Tricuspid valve damage
- Coronary artery to right ventricle fistula
- ↑ Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U; et al. (2007). "The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology". Circulation. 116 (19): 2216–33. doi:10.1161/CIRCULATIONAHA.107.186093. PMID 17959655.
- ↑ 2.0 2.1 Yilmaz A, Kindermann I, Kindermann M, Mahfoud F, Ukena C, Athanasiadis A; et al. (2010). "Comparative evaluation of left and right ventricular endomyocardial biopsy: differences in complication rate and diagnostic performance". Circulation. 122 (9): 900–9. doi:10.1161/CIRCULATIONAHA.109.924167. PMID 20713901.
- ↑ Deckers JW, Hare JM, Baughman KL (1992). "Complications of transvenous right ventricular endomyocardial biopsy in adult patients with cardiomyopathy: a seven-year survey of 546 consecutive diagnostic procedures in a tertiary referral center". J Am Coll Cardiol. 19 (1): 43–7. PMID 1729344.
- ↑ Holzmann M, Nicko A, Kühl U, Noutsias M, Poller W, Hoffmann W; et al. (2008). "Complication rate of right ventricular endomyocardial biopsy via the femoral approach: a retrospective and prospective study analyzing 3048 diagnostic procedures over an 11-year period". Circulation. 118 (17): 1722–8. doi:10.1161/CIRCULATIONAHA.107.743427. PMID 18838566.