Merab SultanaCath Lab TechnologistKing Faisal Specialist Hospital & Research Center

Endomyocardial biopsy is an invasive procedure that allows sampling of heart muscle which can then be sent for histological examination. It is used to establish the diagnosis of heart muscle disease. It is performed with the use of X-ray guidance.

In 1958, Weinberg, fell and Lynfield documented the myocardial and pericardial biopsy of 5 patients. Two of these patients were found to have myocardial diseased.

In 1960, Sutton and Sutton documented 150 biopsies from 54 patients who were suffering from cardiomegaly .

Cont......

In 1965, Bulloch, Morphy, and Perace introduced a heart biopsy needle designed for biopsy of the RV.

Actully the era of modern transvenous endomyocardial biopsy began in Japan in 1962. Konno and Sakakibara developed a new technique with using bioptombioptom catheter.

Bioptom in use today are radiopaque, have stainless steel cutting jaws, are flexible, and promote ease of use by the operator.

Bioptom are availaber in a variety of diameters, 7Fr. and 9Fr available for subclavian and femoral approch.

The lenght of bioptoms 45 or 50cm for subclavian approch and 100cm long for femoral approch.

2. THE EUROPEAN SCHOOL (early ‘70)

A modified bronchoscope biopsy forceps is introduced transvascularly for either right or left ventricle biopsy.

4. TODAY

50% sharper, straight or radial50% sharper, straight or radialtip, 50 - 104 cm.tip, 50 - 104 cm.Tissue sample 5.03 mmTissue sample 5.03 mm33

This is an invasive procedure. It allows direct histological proof for specific heart muscle disease e.g. myocarditis, sarcoidosis, cytotoxic drug related cardiomyopathy or graft rejection after heart transplant. Currently, there is no alternative way to get histological diagnosis apart from a direct sampling.

Evaluation and management of Cardiomyopathy. Evaluation and management of Allografts. Evaluation and managemnet of Idiopathic cardiomyopathy.

› Drug Induced .› Ventricular arrhythmia.

Evaluation and managemnet of restritive or constrictive cardiomyopathy. Cardiac Tumors.

Unexplained myocardial hypertrophy Cardiac Disorders.

› Immune or inflammatory disease.› Degenerative cardiac disease.

EMB specimens are usually obtained from the right ventricle (RV).

Left ventricular (LV) biopsy is rarely performed but can be obtained via an arterial approach. Indications for LV biopsy include suspected cardiac sarcoidosis or myocarditis with primary LV involvement

●Every week for the first four weeks ●Every two weeks for the next six weeks ●Monthly for the next three to four months ●Every three months until the end of the

first year ●Three to four times per year in the second

year ●One to two times per year in subsequent

years

Femoral/ jugular and Subclavian venous approach.

Echo based. Importance of long

sheath Bioptome size Number of samples Location for

sampling Imaging (minimum 15fps)

POINT OF CARE by SonoSite

A 2001 Agency for Healthcare Research and Quality report listed ultrasound-guided ultrasound-guided puncture puncture placement as one of one of the "Top 11 Highly Proventhe "Top 11 Highly Proven" patient safety practices not routinely used in clinical practice

Sonography of the neck is performed to evaluate diameter of the right jugular vein, its relation to the carotid artery and its course, which is marked with a permanent marker.

Juliane Kilo et al. MMCTS 2006;2006:mmcts.2005.001149

© 2006 European Association for Cardio-thoracic Surgery

Local anesthesia is installed with 5–10 ml of Xylocaine 2%.

Juliane Kilo et al. MMCTS 2006;2006:mmcts.2005.001149

© 2006 European Association for Cardio-thoracic Surgery

The preexisting central line is cut, the guide wire inserted through the distal lumen of the catheter and directed to the right atrium.

Juliane Kilo et al. MMCTS 2006;2006:mmcts.2005.001149

© 2006 European Association for Cardio-thoracic Surgery

The advantages of chocardiographically guided endomyocardial biopsy.

1. It does not require the use of the angiographic suite.

2. The patient or operator is not exposed to radiation.3. Because two-dimensional echocardiography equipment is portable,

the procedure can be performed in the intensive care unit or the patient’s room.

4. Biopsy samples can be obtained from multiple areas including theinterventricular septum, apex, and free wall, which may increasethe diagnostic yield.

5. More accurate positioning of the bioptome is achieved with twodimensional echocardiography than with fluoroscopy, especially in heart transplant recipients. At St. Louis University as of 1990 only

two significant complications occurred in 4700 biopsies performedunder echocardiographic guidance over a 5-year period.

Complications of endomyocardial biopsy

1. Access site related (3%)2. Biopsy related (3%)3. Arrhythmia (1%)4. Conduction abnormalities (1%)5. Perforation (0.7%)6. Death (0.4%)

Note: Complication rates are higher for patients with cardiomyopathy than for heart transplant recipients

Femoral, Jugular and Subclavian approch

Right/left internal jugular vein approach

Endomyocardial biopsy is performed in a supine position in local anesthesia. Routine anesthesiologic monitoring (3-lead ECG, non-invasive blood pressure monitoring, oxygen saturation measurement) is placed before the intervention. The head of the patient is placed on a flat cushion to facilitate puncture. The table is positioned head-low to increase central venous filling.

Femoral, Jugular and Subclavian approch

Subclavian vein approach

Endomyocardial biopsy can also be performed via the left or right subclavian vein. However, this approach is not preferable for a variety of reasons: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.

Femoral, Jugular and Subclavian approch

Subclavian vein approach

Due to the anatomical course of the great veins, direction of the bioptome is more difficult.At our institution there are two indications for endomyocardial biopsy via the subclavian vein:If the right internal jugular vein is not susceptible for puncture (e.g. in case of thrombosis), or For patients early after transplantation, who still need a central venous line. In these cases, the introducer sheet can be installed via a preexisting line and/or replaced by a new central venous catheter after the intervention.

RV_ EMB: THE TECHNIQUE (jugular approach)

A.P. viewA.P. view L.A.O viewL.A.O view

By Jugular ApproachedBy Jugular Approached

Femoral approach

A.P. VIEWA.P. VIEW L.A.O. VIEWL.A.O. VIEW

We agree with the following recommendations regarding EMB sampling and analysis based upon the 2007 American Heart Association/American College of Cardiology/European Society of Cardiology scientific statement on the role of EMB and the 2011 consensus statement on EMB from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology .

Cont........................................

Samples should be obtained from more than one region of the RV septum, and the number of samples should range from 5 to 10, depending upon the studies to be performed and size of the bioptome forceps.

●At least four to five samples should be submitted for light microscopic examination.

Cont........................................

●Tandem mass spectroscopy is useful to identify subtypes of amyloid protein.

●At this time, routine testing for viral genomes in EMB specimens is not recommended outside of referral centers with extensive experience in viral genome analysis.

Cont........................................

●Analysis by transmission electron microscopy (TEM) is recommended if anthracycline cardiotoxicity is suspected. TEM is suggested if an infiltrative disorder (eg, amyloidosis) is suspected. TEM is occasionally helpful for identifying viral myocarditis.

If acute rejection is found, histologic review of endomyocardial biopsy is performed to determine the grade of rejection.  

Grade 0 — no evidence of cellular rejection Grade 1A — focal perivascular or interstitial infiltrate without

myocyte injury. Grade 1B — multifocal or diffuse sparse infiltrate without

myocyte injury. Grade 2 — single focus of dense infiltrate with myocyte injury. Grade 3A — multifocal dense infiltrates with myocyte injury. Grade 3B — diffuse, dense infiltrates with myocyte injury. Grade 4 — diffuse and extensive polymorphous infiltrate with

myocyte injury; may have hemorrhage, edema, and microvascular injury.

Thanks for Questions.

Holzmann M, Nicko A, Kühl U, et al. 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 2008; 118:1722.

Cooper LT, Baughman KL, Feldman AM, et al. 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 2007; 116:2216.

Leone O, Veinot JP, Angelini A, et al. 2011 consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology. Cardiovasc Pathol 2012; 21:245.

Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2013; 34:2636.

Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342:1077.

\ Kindermann I, Kindermann M, Kandolf R, et al. Predictors of outcome in patients with suspected myocarditis. Circulation 2008; 118:639

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Special thanks to all for your attention.