Basic of endomyocardial biopsy, sample pathology and some basic informations regarding EMB

1. Merab Sultana
Cath Lab Technologist
King Faisal Specialist Hospital & Research Center

2. 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.

3. 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......

4. 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.

5. 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.

6. 2. THE EUROPEAN SCHOOL (early ‘70)
A modified bronchoscope biopsy forceps is introduced
transvascularly for either right or left ventricle biopsy.

7. 4. TODAY
50% sharper, straight or radial50% sharper, straight or radial
tip, 50 - 104 cm.tip, 50 - 104 cm.
Tissue sample 5.03 mmTissue sample 5.03 mm33

9. 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.

10.  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.

11.  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

12.  ●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

13.  Femoral/ jugular and
Subclavian venous
approach.
 Echo based.
 Importance of long
sheath
 Bioptome size
 Number of samples
 Location for sampling
 Imaging (minimum 15fps)

14. POINT OF CARE by
SonoSite
A 2001 Agency for Healthcare
Research and Quality report
listed ultrasound-guidedultrasound-guided
puncturepuncture placement as one ofone of
the "Top 11 Highly Proventhe "Top 11 Highly Proven"
patient safety practices not
routinely used in clinical
practice

15. 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

16. 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

17. 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

18. 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 the
interventricular septum, apex, and free wall, which may increase
the 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 performed
under echocardiographic guidance over a 5-year period.

19. 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

21.  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.

22.  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.

23.  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.

24. RV_ EMB: THE TECHNIQUE (jugular approach)

25. A.P. viewA.P. view
L.A.O viewL.A.O view
By Jugular ApproachedBy Jugular Approached

26. Femoral approach

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

29.  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........................................

30.  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........................................

31.  ●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........................................

32.  ●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.

33.  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.

34. Thanks for Questions.

35.  Holzmann
M, Nicko A, Kühl U, et al. Complication rate of right ventricular endomyocardial biopsy vi
.
 Cooper
LT, Baughman KL, Feldman AM, et al. The role of endomyocardial biopsy in the managem
.
 Leone O, Veinot JP, Angelini A, et al. 2011 consensus statement on endomyocardial biop
.
 Caforio
AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, ma
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 Felker
GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients wi
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 Kindermann I, Kindermann M, Kandolf R, et al. Predictors of outcome in patients with susp
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36. Special thanks to all for your attention.