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
- 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
- Pneumothorax