Endomyocardial biopsy (EMB) is an invasive procedure used routinely to obtain small samples of

heart muscle Cardiac muscle (also called heart muscle, myocardium, cardiomyocytes and cardiac myocytes) is one of three types of vertebrate muscle tissues, with the other two being skeletal muscle and smooth muscle. It is an involuntary, striated muscle tha ...

, primarily for detecting rejection of a donor

heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide t ...

following

heart transplantation A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease when other medical or surgical treatments have failed. , the most common procedu ...

. It is also used as a

diagnostic tool Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...

in some

heart diseases Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, hea ...

. A bioptome is used to gain access to the heart via a sheath inserted into the right internal jugular or less commonly the

femoral vein In the human body, the femoral vein is a blood vessel that accompanies the femoral artery in the femoral sheath. It begins at the adductor hiatus (an opening in the adductor magnus muscle) as the continuation of the popliteal vein. It ends at th ...

. Monitoring during the procedure consists of performing ECGs and blood pressures. Guidance and confirmation of correct positioning of the bioptome is made by

echocardiography An echocardiography, echocardiogram, cardiac echo or simply an echo, is an ultrasound of the heart. It is a type of medical imaging of the heart, using standard ultrasound or Doppler ultrasound. Echocardiography has become routinely used in t ...

fluoroscopy Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and functio ...

. The risk of complications is less than 1% when performed by an experienced physician in a specialist centre. Serious complications include perforation of the heart with

pericardial tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstruct ...

, haemopericardium,

AV block Atrioventricular block (AV block) is a type of heart block that occurs when the electrical signal traveling from the atria, or the upper chambers of the heart, to ventricles, or the lower chambers of the heart, is impaired. Normally, the sinoa ...

tricuspid regurgitation Tricuspid regurgitation (TR), also called tricuspid insufficiency, is a type of valvular heart disease in which the tricuspid valve of the heart, located between the right atrium and right ventricle, does not close completely when the right ventri ...

and

pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...

. EMB, sampling

myocardium Cardiac muscle (also called heart muscle, myocardium, cardiomyocytes and cardiac myocytes) is one of three types of vertebrate muscle tissues, with the other two being skeletal muscle and smooth muscle. It is an involuntary, striated muscle that ...

was first pioneered in Japan by S. Sakakibra and S. Konno in 1962.

Indications

The main reason for performing an EMB is to assess

allograft Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, o ...

rejection following heart transplantation and sometimes to evaluate

cardiomyopathy Cardiomyopathy is a group of diseases that affect the heart muscle. Early on there may be few or no symptoms. As the disease worsens, shortness of breath, feeling tired, and swelling of the legs may occur, due to the onset of heart failure. A ...

, some

heart disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, hea ...

research and

ventricular arrhythmias Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults ...

, or unexplained ventricular dysfunction.

Transplant monitoring

Visualising the microscopic appearance of the heart muscle allows the detection of cell-mediated or antibody-mediated rejection and is recommended episodically during the first year after heart transplantation. Occasionally, monitoring continues beyond one year. The use of EMB in heart transplant rejection surveillance remains the gold standard test, although the pre-test predictors of rejection

cardiac magnetic resonance imaging Cardiac magnetic resonance imaging (cardiac MRI), also known as cardiovascular MRI, is a magnetic resonance imaging (MRI) technology used for non-invasive assessment of the function and structure of the cardiovascular system. Conditions in which it ...

(CMR) and

gene expression profiling In the field of molecular biology, gene expression profiling is the measurement of the activity (the expression) of thousands of genes at once, to create a global picture of cellular function. These profiles can, for example, distinguish between c ...

, are increasingly used.

Myocardial diseases

EMB has a role in the diagnosis of viral

myocarditis Myocarditis, also known as inflammatory cardiomyopathy, is an acquired cardiomyopathy due to inflammation of the heart muscle. Symptoms can include shortness of breath, chest pain, decreased ability to exercise, and an irregular heartbeat. The ...

and inflammatory myocarditis.

Procedure

EMB of the right ventricle via the internal jugular vein is standard after heart transplant. A bioptome is used to gain access to the heart via a sheath inserted into the right internal jugular or less commonly the

. Monitoring during the procedure consists of performing ECGs and blood pressures. Guidance and confirmation of correct positioning of the bioptome is made by

before the biopsy specimen is taken and in the case of transplants, usually three or four or more samples are taken.

Endomyocardial fibrosis Hypereosinophilic syndrome is a disease characterized by a persistently elevated eosinophil count (≥ 1500 eosinophils/mm³) in the blood for at least six months without any recognizable cause, with involvement of either the heart, nervous sys ...

can occur if biopsies are performed repeatedly. This risk is reduced if the operator is experienced. Unlike for rejection detection, for diagnosing heart disease, different biopsy sites within the heart are targeted. It is possible but less common to biopsy the left ventricle via the

femoral arteries The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the fem ...

Limitations

The accuracy of diagnosis by EMB depends on whether the correct site is biopsied. There is a risk that a diagnosis can be missed if the biopsy misses the diseased part of heart muscle, particularly with myocardial inflammation or fibrosis. An experienced pathologist trained in biopsy analysis and interpretation also reflects EMB’s reliability. Variability between pathologists has been observed.

Complications

A frequent concern regarding EMB has been its safety. However, it has a low risk of less than 1% when performed by an experienced physician in a specialist centre. Possible complications, which almost all occur at time of procedure, include rupture of the right intraventricular septum, conduction block, arrhythmias,

, atrioventricular fistula, and

pulmonary embolism Pulmonary embolism (PE) is a blockage of an pulmonary artery, artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include dyspnea, shortness of breath, chest pain p ...

. Death has been reported, but is rare.

History

Early heart biopsies, sampling

pericardium The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made of ...

, in the latter half of the 1950s were performed through a

cut Cut may refer to: Common uses * The act of cutting, the separation of an object into two through acutely-directed force ** A type of wound ** Cut (archaeology), a hole dug in the past ** Cut (clothing), the style or shape of a garment ** Cut (ea ...

in the left

intercostal space The intercostal space (ICS) is the anatomic space between two ribs (Lat. costa). Since there are 12 ribs on each side, there are 11 intercostal spaces, each numbered for the rib superior to it. Structures in intercostal space * several kinds ...

at the costochondral junction. However this method risked lung and coronary blood vessel damage,

cardiac tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstruct ...

and

arrythmia Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults ...

s. EMB, sampling

, has evolved since it was first pioneered in Japan by S. Sakakibra and S. Konno in 1962. The concept of introducing a biopsy needle through the right internal or external jugular vein to reach the right intraventricular septum for the purpose of sampling the heart muscle was initiated in 1965 by R. T. Bulloch. In 1972, the bioptome and procedure was modified by Philip Caves. This was to allow access

percutaneously {{More citations needed, date=January 2021 In surgery, a percutaneous procedurei.e. Granger et al., 2012 is any medical procedure or method where access to inner organs or other tissue is done via trocar, needle-puncture of the skin, rather than by ...

References

{{DEFAULTSORT:Endomyocardial Biopsy Biopsy Cardiology Medical procedures