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Pathology. Dec;49(7) doi: /cocolmuheatsrar.ml Epub Oct 8. The value of endomyocardial biopsy in diagnosis and guiding therapy.
Table of contents
- Endomyocardial Biopsy
- Paper commented by the Working Group on Myocardial and Pericardial Diseases
- Cardiac amyloidosis
- Endomyocardial Biopsy - The Cardiology Advisor
Learn more. Sign in to My ESC. ESC sub specialties communities. Associations Working Groups Councils. Read your latest personalised notifications Sign in No account yet? Don't miss out Read your latest personalised notifications Ok, got it. Loading quicklinks Background Endomyocardial biopsy EMB remains the gold standard in the diagnosis of myocarditis. Methods A total of patients with suspected myocarditis were investigated.
Results Out of the investigated patients with suspected myocarditis, in 4 patients LV-EMB was not performed in 3 patients due to left ventricle thrombus and in 1 patient due to pericardial tamponade, which occurred during RV-EMB. Conclusion This prospective study shows that biventricular EMB performed by experienced interventionalists is a safe procedure with a low complication rate. Comments The non-invasive diagnosis of myocarditis and other infiltrative or storage cardiac diseases, such as amyloidosis can be challenging.
References A. Yilmaz, I.
Paper commented by the Working Group on Myocardial and Pericardial Diseases
Kindermann, M. Kindermann et al. Comparative evaluation of left and right ventricular endmyocardial biopsy: differences in complication rate and diagnostic performance.
- Biventricular endomyocardial biopsy in patients with suspected myocarditis: Feas?
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Circulation ; Chimenti, A. Contribution and risk of left ventricular endomyocardial biopsy in patients with cardiomyopathies: a retrospective study over a year period. Richardson, W. McKenna, M. Bristow et al. Friedrich, U. Conducting the transthoracic echocardiography immediately after performing the last biopsy or on suspicion of complications during the procedure and monitoring the presence or increase of pericardial effusion or other mechanical complications such as valvular regurgitation. At times ie, on suspicion of inflammatory or infiltrative cardiomyopathy with segmental damage based on prior imaging modalities , it may be useful to perform an electrocardiogram during the procedure in order to be more precise on the location of the specific segment to be biopsized.
Hemodynamic and electrocardiogram monitoring for at least hours at the diagnostics hemodynamics unit in day-hospital care or, in the case of patients already hospitalized, at the intensive care unit, paying special attention to the appearance of any possible complications of vascular access. In the presence of pericardial effusion following the EMB and clinical or echocardiographic data of cardiac tamponade, a pericardiocentesis for drainage purposes should be attempted at the cath.
In most cases, a drainage catheter is inserted and then removed when the amount of drainage fluid is nearly nonexistent and the pericardial effusion has been resolved. In the presence of progressive effusion or hemodynamic instability despite the pericardiocentesis procedure, urgent surgery is indicated to drain the pericardial effusion and repair cardiac perforation.
The description of the procedure is shown at in the supplementary data and in the figure 1. Figure 1. A: Material used to perform EMBs at our center.
On the right side, the bioptome black arrow and the sheath and the 7-Fr multipurpose catheter blue arrow used in right-side EMBs. On the left side, the Endojaw biopsy forceps red arrow and 2 of the sheathless systems used for radial access in left-side EMBs: the JR4 7. B: the latter system described is shown while mounted on a multipurpose catheter at exchange port level.
D: clockwise rotation in the same projection to direct the guidewire catheter towards the septum using an IV contrast to verify its position. The chi-square test was used to compare qualitative variables ant the Student t -test was used for independent sample comparison purposes. After implementing the aforemen- tioned plan, all EMBs were performed under the direct supervision of an experienced interventional cardiologist or by the cardiologist himself.
A total of EMBs were performed in right cavities When it comes to right-side EMBs, the most widely used vascular access was the femoral vein In the case of left-side EMBs, over half of them were performed through the radial artery One of the cases of biventricular EMB required femoral vein puncture and transseptal access, and another one, arterial and femoral vein puncture separately. In Also, it should be mentioned that three of the procedures were electroanatomic mapping-guided EMBs.
Table 1 shows the main procedural characteristics by comparing both stages: before and after the implementation of the plan of action and safety. Overall, a definitive anatomopathological diagnosis was achieved in It is important to stress out that even though the indications were not significantly different in one stage compared to the other, the diagnostic yield improved significantly after the implementation of the plan Also, there was a significant increase in the number of specimens obtained and the number of left-side EMBs.
Endomyocardial Biopsy - The Cardiology Advisor
There was a significant reduction in procedural time with no differences in the x-ray imaging time, although it is true that this difference may have been related with the fact that the isolated EMB without an associated procedure was less common before than after the implementation of the plan It was greater in cases of suspicion of restrictive or infiltrative cardiomyopathy and cardiac tumors. Table 2 shows the anatomical pathology diagnosis in each and every indication.
However, this indication was less common in right-side EMBs All electroanatomic mapping-guided EMBs were performed after the implementation of the plan. The definitive anatomopatho- logical diagnosis was achieved in 2 of the 3 EMBs one case of myocarditis and one case of enteroviral cardiomyopathy. Also, specific therapy was prescribed in both cases.
Table 1. Baseline characteristics and EMB procedural characteristics. Overall and comparisons before and after the implementation of the plan of action and safety. In our series, there were 10 major complications that amounted to a 4. No patient died. All complications occurred while performing the EMB in the right cavities, except for two cases of transient ischemic attack that occurred while performing two left-side EMBs.
Table 3 shows all major complications and their progression. Figure 2 shows the main major complications that took place in our series before and after the implementation of the plan of action and safety. It is important to say that after the implementation of this plan the major complications were cut in half from 7. This decrease was due to less cases of cardiac perforation with only one case being reported after the implementation of the plan 6. Figure 2.
Major complications associated with the EMB before and after the implementation of the plan of action and safety. EMB, endomyocardial biopsy.
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TIA, transient ischemic attack. Even though over the last few years we have not had any significant advances in the non-invasive diagnosis of acute rejection in heart transplant recipients 11 , 12 or in the non-invasive diagnosis of different cardiomyopathies, 13 - 16 the EMB is still the gold standard procedure to achieve a definitive diagnosis in these situations.
The findings of the EMB can also have relevant prognostic implications. However, the diagnostic yield of this technique is not absolute and varies from one series published to the next table 4. It is interesting to see how the diagnostic yield of our series improved significantly after the implementation of the plan basically to the detriment of an improved diagnostic yield in cases of ventricular dysfunction or on suspicion of myocarditis.
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The advances made in immunohistochemical techniques and genomic detection methods, the planning of all cases by choosing the most suitable approach for each patient based on the type of cardiomyopathy suspected , the experience accumulated, and the acquisition of a larger amount of specimens in every procedure are some of the reasons that would justify such a change. In our series, the rate of complications is higher. The fact that the most common indication in our center was for the study of ventricular dysfunction could explain this, since this group of patients has a higher risk of complications.
We believe that our results show a more realistic situation of EMBs currently performed in our setting. Therefore, we believe that this type of procedure should not be trivialized and should be performed at centers with enough experience and under the supervision and rules from a clear-cut plan of action of safety. Table 2. Diagnostic yield in each and every EMB indication.
The overall diagnostic yield of the entire series is shown here as well as the comparison between the 2 stages before and after the implementation of the plan of action and safety in the 2 main indications.
The definitive anatomopathological diagnosis of each indication is expressed as absolute numbers and percentages using brackets. Table 3. Summary of major complications in chronological order of appearance. Table 4. Diagnostic yield and major complications in the main EMB series in the non-transplant setting published to date. The percentages of the EMB locations are the ones provided by each center.
The vascular access used by the different centers varied, mostly venous access and through the femoral artery. The table disregards the EMBs performed in the transplant setting. The rate of major complications includes one composite variable of pericardiocentesis, surgery or temporary pacing.