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ENDOMYOCARDIAL
BIOPSY
Claudio Moretti
School of Cardiology - University of Turin
Department of Medicine Turin-Asti - Italy
ENDOMYOCARDIAL BIOPSY
1. STONE AGE
NEEDLE BIOPSY
2. FIRST “JAP” ENDOVASCULAR ATTEMPTS
1962 – SAKAKIBARA AND KONNO
Introduced a transvascular approach
to obtaining endomyiocadial tissue.
The device was so large that access to
a vessel was difficult.
One series of over 450 pts in Japan
underwent the procedure without
complication.
2. THE EUROPEAN SCHOOL (early ‘70)
A modified bronchoscope biopsy forceps is introduced
transvascularly for either right or left ventricle biopsy.
3. THE AMERICAN SCHOOL (mid-1970s)
Developed by Caves et al for assessment of cardiac rejection
4. TODAY
50% sharper, straight or radial
tip, 50 - 104 cm.
Tissue sample 5.03 mm3
EMB: tips & tricks
 Central vein puncture
 RV_EMB / Jugular approach
 RV EMB / Femoral approach
Patient positioning
1. Trendelemburg
2. Do not over-rotate
3. Valsalva ?
POINT OF CARE ECHO
A 2001 Agency for Healthcare
Research and Quality report listed
ultrasound-guided central line
placement as one of the "Top 11
Highly Proven" patient safety
practices not routinely used in
clinical practice
RV_ EMB: THE TECHNIQUE (jugular approach)
A.P. view
L.A.O view
Femoral approach
A.P. VIEW
L.A.O. VIEW
EMB: COMPLICATIONS
 Single-centers experiences
 Repetitive procedures after H.TX
 Largest series reported by Holzmann et al
3048 RV.EMB - 0,12% major complications

0,28 – 3.3 %
“ further investigations are necessary to prove
the procedural risk and diagnostic value of
LEFT VS RIGHT EMB”.
2007 AHA/ACC/ESC The role of EMB in the management of CV disease
 PROCEDURAL SAFETY
 DIAGNOSTIC PERFORMANCE
 SELECTIVE OR BIV. EMB
 SUSPECTED MYOCARDITIS
 STATE OF THE ART TECHNIQUE
SETTING
 2 UNIVERSITY HOSPITALS
 EXPERIENCED INTERVENTIONALISTS (> 3 yrs exp)
 755 pts (529 + 226)
 NO F.up. EMB, NO Heart TX follow up
 PRE-POST ECHO
 71.5 % CMR (no edema-detect seq)
POPULATION
265 SELECTIVE LEFT EMB
133 SELECTIVE RIGHT EMB
357 BIVENTRICULAR
EMB
LV_ EMB
 7F Cordis sheath
 2.500 Heparin (ACT 150 sec)
 7F guiding cath (JR 4, AL 1, JL 4)
 inferior, posterior, lateral and apical EMB with JR4
 anterior segments with AL 1
MAJOR COMPLICATIONS
6361 EMBs
755 PTS (622 left EMB & 490 right EMB)
2 PERFORATIONS
2 STROKES
0.64
4 PERFORATIONS
0.82
BIV. EMB
1.51
MINOR COMPLICATIONS
14 PERICARDIAL EFFUSIONS + 1 TEMP P.M.
DIAGNOSTIC PERFORMANCE
Which EMB approach gives the highest nr of diagnostic results ?
BIVENTR. EMB
VS LEFT VENTR. EMB
+ 7,1 %
BIVENTR. EMB
VS RIGHT VENTR. EMB
+ 12,6 %
DIAGNOSTIC RELEVANCE
of a CMR-Guided EMB
CMR has been proposed as a tool to direct EMB
Surprisingly ,
in 292 pts with biventr EMB / CMR_LGE +
NO differences in the number of diagnostic EMBs when related to
The site of LGE
2011
Although the pathological demonstration of myocardial
degeneration and fibrofatty replacement is regarded as the
diagnostic “gold standard,”
EMB has not been consistently helpful
in recognizing the disease partly
owing to its
patchy
nature and lack of histological abnormalities at early stages
FINAL REMARKS
 COMPLICATION RATE of 0.64% (LV) AND 0,82% (RV)
I.E. LV/RV EMB IS A SAFE PROCEDURE
 DIAGNOSTIC EMB RESULTS WERE OBTAINED MORE
OFTEN IN BI-V EMBs (79,3%) COMPARED TO SELECTIVE
LV- OR SELECTIVE RV- (67.3%)
 NO DIFFERENCES IN NR OF DIAGNOSTIC EMBs
WHEN RELATED TO THE SITE OF CMR-BASED LGE
 LV-EMB SHOULD BE PREFERRED IF MINIMIZING THE
LENGHT OF THE PROCEDURE IS A CONSIDERATION
(HIGHER DX YIELD AND LOWER RISK !)
Thanks a lot !