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Endomyocardial biopsy
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
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Introduction to EMB by Dr. Kiran Kumar, describing it as a diagnostic technique for cardiac disorders.
Evolution of EMB techniques from surgical biopsies in the 1950s to current catheter-based methods.
Necessary preparations before EMB: lab tests, ECG, chest X-ray, fasting, and location setup.
Explanation of transvascular approach and specifics of the procedure using catheterization.
Detailed visuals and descriptions of bioptome forceps and sheath used in EMB.
Routine processing of biopsy fragments, including different treatments based on clinical indications.
Primary and secondary indications for performing EMB, especially in cardiac dysfunction cases.
Sampling limitations and interpretation problems in EMB leading to potential diagnostic challenges.
Risks associated with EMB, including perforation and complications specific to certain patient groups.
Different grades of transplant rejection assessed through EMB, providing specific criteria.
Varied cardiac conditions evaluated using EMB, including CMV infection, myocarditis, and others.
Summary of EMB's importance in assessing graft rejection and advancements reducing procedural risks.
Listing references and textbooks for further reading on surgical pathology and cardiology.
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Endomyocardial biopsy
- 1. ENDOMYOCARDIAL BIOPSY Dr E KiranKumar 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 • Opensurgical 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 THEPATIENT • 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 viathe 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.
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- 12. Tissue Processing • 4-5biopsy 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 Mostcommon 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) • Lesscommon 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 • Majorlimitation- 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 • Samplingerror-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 – CLINICALPERFORATION (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.
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- 24. PREVIOUS BIOPSY SITEAND QUILTY EFFECT
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- 31. DILATED CMP- HPVIEW
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- 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).
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- 45. SARCOIDOSIS OF HEART-NON CASEATING GRANULOMA
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- 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 –principlesand 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.