Endomyocardial biopsy is a technique where heart tissue is sampled from patients with suspected cardiac disorders. Historically, open surgical biopsies were performed in the 1950s, followed by needle biopsies using modified biopsy tools. The first transvenous biopsy tool was developed in Japan in 1962. Endomyocardial biopsy is now commonly performed via the internal jugular or femoral vein to obtain tissue samples from the right ventricle for microscopic examination. Potential indications include evaluating unexplained cardiomyopathy, diagnosing myocarditis, investigating transplant rejection, and assessing drug toxicity. Complications can include perforation, arrhythmias, pneumothorax, and hemopericardium. The biopsy tissue allows for diagnosis and monitoring of various

1. ENDOMYOCARDIAL
BIOPSY
Dr E Kiran Kumar
Professor of Pathology
MIMS, Vizianagaram,A.P

2. What is EMB ?
• Endomyocardial Biopsy(EMB) is a
technique by which heart tissue is
sampled from the pts with suspected
cardiac disorders for microscopic
diagnosis and evaluation of the lesions.

3. HISTORICAL ASPECTS
• Open surgical biopsies of heart-1950’s, followed
by needle bx using modified vim-silverman’s
needle through thoracotomy/trans-thoracic
approach- complications like pneumothorax/
cardiac tamponade. .
• The first trans-venous biopsy fx- KONNO-
SAKAKIBARA BIOPTOME- Japan-1962.
• Modified bioptome- CAVES-SCHULTZ-
STANFORD bioptome- Stanford-1972.

4. HISTORICAL ASPECTS (cont’d)
• Further modifications in catheter design-
sheathing and increased flexibility and easy
manouverability, e.g Modified Cordis Bioptome.
• Novel-shaped long-neck sheath for
endomyocardial biopsy through the internal
jugular approach- reduces trauma and provides
stability for the bioptome forceps,limits
radiation exposure.
• EMB –Initially performed via the “internal
jugular vein”, later- femoral venous approach is
used after the advent of long and flexible
bioptomes.

5. PREPARATION OF THE PATIENT
• Routine lab tests, an ECG and a chest x-
ray.
• Pt should have nothing to eat or drink, 6
hrs before the procedure, except the
medication.
• Done in Cardiac Catheterization lab.
• Anaesthetic medication used- novocaine.

6. TECHNIQUE
• Performed via the transvascular approach
and is done usually at the time of cardiac
catheterization.
• Right ventricle is preferred as it is easier
and safer to biopsy this chamber.
• Rt ventricle is the representative site in
diffuse diseases. Lt ventricle is preferred
in sarcoidosis and done via arterial
approach.

7. Technique (cont’d)
A flexible, plastic tube called a “sheath” is inserted into the
vein in the neck or groin, followed by insertion of
“pulmonary artery catheter” into the rt side of heart
( under fluoroscopic guidance), which measures the
pressures inside the heart. Then the catheter is removed.
• Then BIOPTOME is guided through the sheath into the
heart. Biopsy forceps can easily be taken upto the apical
portion of RVS.3-4 tissue samples of 2-3 mm size are
obtained.Then the bioptome and sheath are removed.
• Flexible, disposable bioptomes- presently available.
• Availability of catheters and bioptome forceps of
different sizes and designs - Apical curvature- for easy
sampling and grip on the tissue.

8. •Bioptome
forceps with
sheath

10. BIOPTOME FORCEPS

11. BIOPTOME FORCEPS WITH
SHEATH

12. Tissue Processing
• 4-5 biopsy fragments are processed
routinely and 1 fragment for EM exam.
• Transplant biopsies- if vascular rejection is
suspected, 1 fragment is frozen for
immunofluorescence.
• Anthracycline, Chloroquine and
Amiodarone toxicity- All fragments are
processed for EM.

13. INDICATIONS FOR EMB
Most common indications are-
1) To evaluate unexplained CCF
2) To diagnose myocarditis
3) Constrictive v/s Restrictive CMPs
4) To diagnose transplant rejection
5) To evaluate drug (anthracycline,herceptin,doxorubicin
) toxicity
6) To investigate effects of anabolic steroids, thalassemia
and HIV cardiomyopathy).
## “EMB is the most useful tool for the diagnosis and
monitoring of cardiac allograft rejection after cardiac
transplantation.” ##

14. INDICATIONS (cont’d)
• Less common indications are
1) To investigate idiopathic arrythmias
2) Biopsies of neoplasms .
One impt indication for Lt ventr bx-
“suspected cardiac sarcoidosis”- Involves
lt vent > rt vent – An arterial approach is
reqd for lt vent biopsy.

15. TISSUE EVALUATION
• Major limitation- SAMPLING
• Bioptome is guided towards the apex of the right
ventricle, yielding tissue from the ventricular
septum or right ventricular wall.
• FOCAL INVOLVEMENT -Inflamm and Infiltr
diseases like myocarditis, haemochromatosis,
sarcoidosis and amyloidosis . Hence easily
MISSED by biopsy.
• Hence SERIAL SECTIONING of multiple
sections through the block required.

16. PROBLEMS DURING
INTERPRETATION
• Sampling error-due to focal nature of disease
(e.g. myocarditis)
• Crush artifacts-mech trauma
• Contraction bands(AMI, Mech trauma)
• Focal interstitial fibrosis (non- specific finding)
• Interstitial mesenchymal cells closely resemble
lymphocytes.
• Endocardial thickening( non specific finding)
• Adipose tissue (normal in rt ventr biopsy)

17. COMPLICATIONS
PERFORATION – CLINICAL PERFORATION
(chest pain and pericardial effusion as judged by
transthoracic echocardiography or TEE) and
``NEAR PERFORATION'' (epicardial fat in
specimens.
• The risk of perforation can be reduced by using
a specially curved sheath to guide the biopsy
forceps toward the interventricular septum.
• Others- mostly in pediatric age group-
Arrythmias(AF/VF), Pneumothorax and
Haemopericardium.

18. TRANSPLANT REJECTION-
GRADING

19. TRANSPLANT REJECTION-GR 3B

20. TRANSPLANT REJECTION- GR3B

21. TRANSPLANT REJECTION GR 3A

22. TRANSPLANT REJECTION GR- 4

23. CMV INFECTION IN
ALLOGRAFT

24. PREVIOUS BIOPSY SITE AND
QUILTY EFFECT

25. MYOCARDITIS

26. HEMOCHROMATOSIS

27. DRUG TOXICITY

28. DOXORUBICIN TOXICITY

29. DILATED CMP

30. DILATED CMP

31. DILATED CMP- HP VIEW

32. DILATED CMP- MASSON’S
TRICHROME STAIN

33. Figure 1 (A) Biopsy from a 45 year old woman with dilated cardiomyopathy. Note the
endocardial fibrosis, myocyte hypertrophy, myocyte nuclei, and moderate interstitial
fibrosis (haematoxylin and eosin staining; original magnification, x10). (B) Elastic
trichrome stain of the same case showing thickened fibrous endocardium with
considerable interstitial fibrosis (original magnification, x10).

34. MYOCARDITIS

35. MYOCARDITIS- HP VIEW

36. GIANT CELL MYOCARDITIS

37. GIANT CELL MYOCARDITIS-HP
VIEW

38. EOSINOPHILIC MYOCARDITIS

39. CARDIAC AMYLOIDOSIS

40. CARDIAC AMYLOIDOSIS-
CRYSTAL VIOLET STAIN

41. CARDIAC AMYLOIDOSIS-
THIOFLAVIN T STAINING

42. CARDIAC AMYLOIDOSIS-
BLOOD VESSELS

43. RESTRICTIVE CMP

44. RESTRICTIVE CMP- MASSON’S
TRICHROME STAIN

45. SARCOIDOSIS OF HEART- NON
CASEATING GRANULOMA

46. TUBERCULOMA HEART-
CASEOUS NECROSIS

47. GLYCOGEN STORAGE DISEASE

48. ##TAKE HOME MESSAGE ##
• Endomyocardial biopsy is an inevitable and an efficient
investigative tool for assesment of rejection grading of
the allograft after CARDIAC TRANSPLANTAION.
• There is a significant REDUCTION in the incidence of
complications of the procedure, due to the NEWER
MODIFICATIONS in the DESIGNING of the sheath and
bioptome forceps.
• Done in CARDIAC CATHETERISATION LAB, in the
presence of interventional cardiologist, and under
FLUOROSCOPIC guidance.
• Sampled heart tissue can be subjected to ROUTINE
TISSUE PROCESSING for HPE, ANCILLIARY
techniques like IHC, Enzyme Histochemistry, Special
Stains, ,EM, Molecular Phenotyping ,RT- PCR techniques
for detection of viral nuclei acids,etc.

49. RESOURCE MATERIAL
1)Silverberg’s –principles and practice of surgical
pathology and cytopathology.
2)Chopra’s-Text book of cardiovascular pathology.
3)Sternberg’s –Diagnostic surgical pathology.
4)Weidner’s – Modern Surgical Pathology
5) Anderson’s - Pathology
6) Internet -Cardiology and pathology journal
websites.