- Leslie T Cooper, Jr, MD
Leslie T Cooper, Jr, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
- Section Editors
- William J McKenna, MD
William J McKenna, MD
- Section Editor — Myopericardial Disease
- Professor of Cardiology
- University College, London
- Sharon A Hunt, MD
Sharon A Hunt, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Heart Transplantation
- Professor of Medicine
- Stanford University School of Medicine
- Heidi M Connolly, MD, FASE
Heidi M Connolly, MD, FASE
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
Interest in the use of endomyocardial biopsy (EMB) as a diagnostic tool for patients who present with abnormal systolic or diastolic function has grown as the technique has been refined and perfected. The first transvenous EMB forcep, the Konno-Sakakibara bioptome, was developed in Japan in 1962 . A modified bioptome, the Caves-Schultz-Stanford bioptome, was developed in 1972, and versions of this device are still widely used . Flexible bioptome devices with smaller jaws have been developed and are associated with very low complication rates . Declines in the procedural risk of EMB and increasing evidence of its value in diagnosis and guiding therapy are extending the role for EMB at medical referral centers with necessary technical expertise.
Monitoring for allograft rejection after cardiac transplantation is the strongest indication for EMB. (See "Acute cardiac allograft rejection: Diagnosis".) The role for this procedure in other disorders, such as myocarditis and idiopathic dilated cardiomyopathy, has been more controversial.
The general role of EMB in cardiovascular disease will be reviewed here. The importance in individual diseases will be discussed in detail on the appropriate topic reviews.
Access and imaging — Endomyocardial biopsy (EMB) was initially performed via the internal jugular vein and the right internal jugular vein remains the most common access site in the United States. However, the advent of long, flexible bioptome devices permits a femoral venous approach with equal efficacy.
EMB is usually performed with fluoroscopic guidance. Transthoracic echocardiography is increasingly used in conjunction with fluoroscopy in an effort to reduce the risk of cardiac perforation. Echocardiography also allows visualization of biopsy location, which is important to confirm that the same site is not repeatedly biopsied and for conditions such as intracardiac mass.
- SAKAKIBARA S, KONNO S. Endomyocardial biopsy. Jpn Heart J 1962; 3:537.
- Caves PK, Schulz WP, Dong E Jr, et al. New instrument for transvenous cardiac biopsy. Am J Cardiol 1974; 33:264.
- 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 Jr. Right from the heart: when should myocardial biopsy be performed for suspected arrhythmogenic right ventricular cardiomyopathy/dysplasia? Eur Heart J 2008; 29:2705.
- Cooper LT Jr. Role of left ventricular biopsy in the management of heart disease. Circulation 2013; 128:1492.
- Ardehali H, Howard DL, Hariri A, et al. A positive endomyocardial biopsy result for sarcoid is associated with poor prognosis in patients with initially unexplained cardiomyopathy. Am Heart J 2005; 150:459.
- Yilmaz A, Kindermann I, Kindermann M, et al. Comparative evaluation of left and right ventricular endomyocardial biopsy: differences in complication rate and diagnostic performance. Circulation 2010; 122:900.
- Chimenti C, Frustaci A. Contribution and risks of left ventricular endomyocardial biopsy in patients with cardiomyopathies: a retrospective study over a 28-year period. Circulation 2013; 128:1531.
- 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.
- Vrana JA, Gamez JD, Madden BJ, et al. Classification of amyloidosis by laser microdissection and mass spectrometry-based proteomic analysis in clinical biopsy specimens. Blood 2009; 114:4957.
- 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.
- Caforio AL, Calabrese F, Angelini A, et al. A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis. Eur Heart J 2007; 28:1326.
- Frustaci A, Chimenti C, Calabrese F, et al. Immunosuppressive therapy for active lymphocytic myocarditis: virological and immunologic profile of responders versus nonresponders. Circulation 2003; 107:857.
- Liang JJ, Hebl VB, DeSimone CV, et al. Electrogram guidance: a method to increase the precision and diagnostic yield of endomyocardial biopsy for suspected cardiac sarcoidosis and myocarditis. JACC Heart Fail 2014; 2:466.
- Mahrholdt H, Goedecke C, Wagner A, et al. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation 2004; 109:1250.
- Lee JC, Seiler J, Blankstein R, et al. Images in cardiovascular medicine. Cardiac sarcoidosis presenting as heart block. Circulation 2009; 120:1550.
- Frustaci A, Russo MA, Chimenti C. Randomized study on the efficacy of immunosuppressive therapy in patients with virus-negative inflammatory cardiomyopathy: the TIMIC study. Eur Heart J 2009; 30:1995.
- Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.
- Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
- McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
- Kandolin R, Lehtonen J, Salmenkivi K, et al. Diagnosis, treatment, and outcome of giant-cell myocarditis in the era of combined immunosuppression. Circ Heart Fail 2013; 6:15.
- Kalra A, Kneeland R, Samara MA, Cooper LT Jr. The Changing Role for Endomyocardial Biopsy in the Diagnosis of Giant-Cell Myocarditis. Cardiol Ther 2014; 3:53.
- Hill KD, Atkinson JB, Doyle TP, Dodd D. Routine performance of endomyocardial biopsy decreases the incidence of orthotopic heart transplant for myocarditis. J Heart Lung Transplant 2009; 28:1261.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 62:e147.
- 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.
- Frustaci A, Caldarulo M, Buffon A, et al. Cardiac biopsy in patients with "primary" atrial fibrillation. Histologic evidence of occult myocardial diseases. Chest 1991; 100:303.
- Sekiguchi M, Take M. World survey of catheter biopsy of the heart. In: Cardiomyopathy: Clinical, Pathological and Theoretical Aspects, Sekiguchi M, Olsen EG (Eds), University Park Press, Baltimore 1980. p.217.
- Access and imaging
- Right or left ventricle
- Sampling and analysis
- EMB recommended
- - Fulminant HF
- - Early AV block, arrhythmias, or refractory HF
- EMB suggested in selected cases
- - Late AV block, arrhythmias, or refractory HF
- - DCM with eosinophilia
- - Anthracycline cardiotoxicity
- - Restrictive cardiomyopathy
- - Selected cardiac tumors
- - Unexplained cardiomyopathy in children
- - HCM with HF
- - ARVC
- EMB of unproven value
- - General evaluation of heart failure
- - Recent onset DCM
- - Chronic DCM
- - Unexplained arrhythmias
- - Unexplained atrial fibrillation
- SUMMARY AND RECOMMENDATIONS