Indications For Endomyocardial Biopsy Research Articles

Management of acute myocarditis: a systematic review of clinical practice guidelines and recommendations.

The management of acute myocarditis (AM) is addressed in multiple clinical guidelines. We systematically reviewed current guidelines developed by national and international medical organizations on the management of AM to aid clinical practice. Publications in MEDLINE, EMBASE and Cochrane were identified between 1 January 2013 and 12 April 2024. Additionally, the websites of relevant organizations and the Guidelines International Network, Guideline Central, and NHS knowledge and library hub were reviewed. Two reviewers independently screened titles and abstracts, two reviewers assessed the rigour of guideline development, and one reviewer extracted the recommendations. Two of the three guidelines identified showed good rigour of development. Those rigorously developed agreed on the definition of AM, sampling serum troponin as part of the workflow for AM, testing for B-type natriuretic peptides in heart failure, key diagnostic imaging in the form of cardiovascular magnetic resonance, coronary angiography to exclude significant coronary disease, indications for endomyocardial biopsy (EMB), and indications for immunosuppression and advanced treatment options. Discrepancies exist in sampling creatine kinase-myocardial bound as a marker of myocardial injury, indications for EMB, and indications for immunosuppression and treatment of uncomplicated AM. Evidence is lacking for the use of 18F-Fluorodeoxyglucose Positron Emission Tomography for myocardial imaging, exercise restriction, follow-up measures and genetic testing, and there are few high-quality randomized trials to support treatment recommendations. Recommendations for management of AM in the guidelines have largely been developed from expert opinion rather than trial data.

Post-COVID morphologically proved endocarditis: infective and nonbacterial forms

PurposeTo study clinical features of endocarditis and its possible mechanisms (infective and nonbacterial) in the long-term period after acute COVID-19.MethodsThree patients (two male and one female, age 64, 39 and 46 years) diagnosed with postcovid endocarditis were included in the study. One patient had severe bilateral coronavirus pneumonia; the other two had only fever and weakness. The diagnosis of COVID-19 was confirmed by seroconversion. The time of admission after COVID-19 was from 4 to 7 months. All patients had study for anti-heart antibodies (AHA), EchoCG, Holter ECG, and endomyocardial biopsy (EMB) with PCR for SARS-Cov2 and cardiotropic viruses. The indication for EMB was suspected myocarditis. Blood cultures and procalcitonin levels were tested in one patient due to a prolonged febrile fever.ResultsTwo variants of postcovid endocarditis have been diagnosed. The first variant was detected in two patients by EMB only. This patients had severe lymphocytic and giant cell myocarditis. In addition, EMB showed signs of lymphocytic endocarditis with infiltrates, marked thickening and fibrosis of the endocardium (Fig. 1). Some biopsy specimen were represented by fresh thrombotic masses, infiltrated with neutrophilic leukocytes. No intraventricular thrombus was detected on EchoCG and MRI. The second variant of postcovid endocarditis developed in a patient with bicuspid aortic valve and met the criteria of infectious endocarditis 2015: mobile vegetations on the valve with aortic regurgitation II, splenomegaly, irregular fever up to 39°C for six months, marked increase of CRP, procalcitonin and ferritin, hypochromic anemia, LV EF 25%. Blood culture was negative. After intravenous therapy with antibiotics and immunoglobulin, EMB confirmed the active lymphocytic myocarditis and only slight fibrosis of right ventricular endocardium. The bacteriological study of endocardium was negative. SARS-Cov-2 RNA was detected by PCR in myocardial biopsy specimens of two patients; the biopsy of one patient is in the study now. All patients had significantly elevated antibody titers to various cardiac antigens, but the level of antibodies to endothelial antigens remained completely normal. It is possible to suggest an active deposition of immune complexes in the endothelium. Two surviving patients receive steroid therapy (in case of IE with antibiotics).ConclusionsSARS-Cov-2 infection induces the prolonged non-bacterial thromboendocarditis or infective endocarditis. In both cases, autoimmune mechanisms play a significant role, as evidenced by the simultaneous lymphocytic/giant cell myocarditis and high titers of AHA. Long-term persistence of coronavirus in the myocardium can also be considered as an etiological factor of endocarditis. In favor of this hypothesis is the parietal thrombosis in the absence of bacterial infection. Corticosteroids and anticoagulants should be considered for the treatment of postcovid endocarditis.Funding AcknowledgementType of funding sources: None. Figure 1. The EMB in in postcovid endocarditis

Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy.

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant (HTx) rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples have significantly improved diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (i) an overview of the practical approach to EMB, (ii) an update on indications for EMB, (iii) a revised plan for HTx rejection surveillance, (iv) the impact of multimodality imaging on EMB, and (v) the current clinical practice in the worldwide use of EMB.

Heart Failure Association, Heart Failure Society of America, and Japanese Heart Failure Society Position Statement on Endomyocardial Biopsy

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumors. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples has significantly improved the diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (1) an overview of the practical approach to EMB, (2) an update on indications for EMB, (3) a revised plan for heart transplant rejection surveillance, (4) the impact of multimodality imaging on EMB, and (5) the current clinical practice in the worldwide use of EMB.

Does cardiac magnetic resonance imaging complement or replace endomyocardial biopsy in the diagnosis of myocarditis? In the era of cardiac magnetic resonance imaging, indications for endomyocardial biopsy are limited

Does cardiac magnetic resonance imaging complement or replace endomyocardial biopsy in the diagnosis of myocarditis? In the era of cardiac magnetic resonance imaging, indications for endomyocardial biopsy are limited

Acute Thrombus Formation as a Complication of Right Ventricular Biopsy

While using echocardiography to guide endomyocardial biopsy (EMB), the authors have identified acute intracardiac thrombus formation related to the procedure, a hitherto unreported complication. The aims of this study were to identify the procedural details and characteristics of patients who developed this complication between June 2008 and April 2009 and to describe their outcomes and management. In total, 415 right ventricular biopsies were performed during this period. Of these, 189 were echocardiographically guided, and the medical records of these patients were reviewed retrospectively. There were eight cases of acute right-sided intracardiac thrombus formation in seven patients (about 4% of the echocardiographically guided group) at the time of biopsy. The indications for EMB were heart transplant surveillance in six patients and suspected cardiac amyloidosis in one patient. Three cases were performed via a transjugular approach and four via a femoral approach. Four patients had histories of prior thromboses, and one patient had a defined clotting diathesis. Management included either immediate thrombus aspiration or postprocedural anticoagulation. There were no overt occurrences of pulmonary thromboembolism. Acute thrombus formation is a complication of EMB. If this complication is unrecognized, and therefore untreated, pulmonary thromboembolism may result. This may have important clinical implications in patients undergoing routine repeated surveillance EMB after cardiac transplantation. The authors recommend performing transthoracic echocardiography during EMB, particularly in patients with histories of thrombosis, because this group of patients may be at increased risk for procedural thrombosis, and procedural echocardiography permits early recognition and treatment of this complication.

The role of endomyocardial biopsy in the management of cardiovascular disease: a commentary on joint AHA/ACC/ESC guidelines

Data on the use of endomyocardial biopsy (EMB) in routine cardiological practice are scant, but anecdotal evidence suggests that its frequency varies substantially between centres. The reasons for this variation...

A 32‐year‐old woman with arthralgias and severe hypotension

A 32‐year‐old woman with arthralgias and severe hypotension

Endomyocardial biopsy - jugular/subclavian vein approach

Endomyocardial biopsy (EMB) is a diagnostic procedure mainly to survey the sufficiency of immunosuppressive therapy after cardiac transplantation. Other indications for EMB remain controversial. After insertion of an introducer sheet in Seldinger's technique, four to six biopsies are taken from the right ventricle by fluoroscopic guidance. EMB is a very safe operation with a low complication rate which can be rapidly performed with little inconvenience for the patient if performed by a skilled surgeon.

Diagnostic approach to the patient with cardiomyopathy: Whom to biopsy

The prevalence of congestive heart failure is increasing and the prognosis remains poor. Cardiomyopathy is one of the most frequent causes of congestive heart failure and is the most common etiology of patients submitted to heart transplant. Determination of the etiology of cardiomyopathy has both prognostic and therapeutic implications. History, physical examination, transthoracic echocardiogram, selected laboratory studies, and coronary angiography can often define the cause of cardiomyopathy, however, the etiology occasionally remains unknown despite this initial evaluation. The indications for endomyocardial biopsy (EMBx) in patients with cardiomyopathy and a negative initial evaluation remains uncertain. The search for Dallas histological criteria proven myocarditis prompted the performance of EMBx in patients with unexplained cardiomyopathy in hopes of identifying an etiology for which treatment would result in improvement in left ventricular function. The "negative" results of the Myocarditis Treatment Trial, with treated and controlled patients improving equally, dampened enthusiasm for this diagnostic procedure. However, our experience and recent evidence suggests that EMBx may be a valuable diagnostic modality and should be included in the evaluation of patients with initially unexplained cardiomyopathy.

Infection and inflammation in the cardiovascular system.

Infectious disease is one of the few genuine adventures left in the world. Hans Zinsser (1878–1940), Rats, Lice and History Infection and inflammation of the cardiovascular system are a frequent cause of cardiac and/or vascular disease, which represents an enormous clinical burden in adult medicine. Major advances have now occurred in understanding cellular and molecular bases of a wide variety of inflammatory cardiovascular diseases. Some of these (myocarditis) have been recognized as inflammatory disease for a long time. Of others (atherosclerosis), the inflammatory nature of disease and possible involvement of bacterial antigens therein has emerged only recently. In both cases however, new insights in inflammatory mechanisms will have great impact on clinical thinking and management. Therefore, Cardiovascular Research has decided to devote a spotlight issue to this topic. This issue contains 10 review articles that provide state-of-the-art knowledge and, in addition, 14 original papers with novel data on the intriguing relationship between infection/inflammation and cardiovascular disease. Historically, myocarditis has been the cause of a great deal of clinical and pathologic confusion and debate. Though the term myocarditis goes back to the 1800s, it was only in 1941 that histologic myocarditis was discerned from ischemic heart disease. Until the introduction of the endomyocardial bioptome in 1962, myocarditis was diagnosed during life often presumptive and not always correct, mainly in young patients with heart failure preceded by a febrile illness. Most cases were diagnosed as late as at autopsy. Confusion was further heightened by lack of agreement among clinicians regarding indications for endomyocardial biopsy as well as interpretation of biopsy findings. Histologic criteria for myocarditis are still a matter of debate among pathologists, and it has become now increasingly apparent that more attention should be given to serologic, molecular and immunologic factors in order to fully characterize the disease. According to the … *Corresponding author. Tel.: +31-20-566-5633; fax: +31-20-691-4738. Email address: a.c.vanderwal{at}amc.uva.nl

A new technique for endomyocardial biopsy in infants and small children

Endomyocardial biopsy (EMB) is usually performed from the femoral veins in infants and small children. This requires the use of a long vascular sheath to direct a bioptome to the ventricular septum. We describe a technique of EMB in this population that obviates the need for the use of a long vascular sheath. A 5 Fr 0.038" internal diameter, no-sideholes Cobra catheter (Cook, Bloomington, IN) introduced via a 5 Fr short sheath was used to direct a 3 Fr, 60-cm-length Cook bioptome to the ventricular septum. From January 1998 to August 1999, this technique was used 22 times in seven patients for EMB (median, age 13 months; range, 1-72 months). Indications for EMB in this group were posttransplantation surveillance (21 times) and evaluation for cardiomyopathy/myocarditis (1). Median number of EMB specimens obtained per procedure was 6 (range, 5-9). There was one pneumopericardium seen post-EMB with this technique without hemodynamic embarrassment. EMB in infants and small children can be performed successfully, safely, and repeatedly from the femoral veins without the need for a long sheath.

Efficacy of 100 consecutive right ventricular endomyocardial biopsies in pediatric patients using the right internal jugular venous approach.

Indications for endomyocardial biopsy (EMB) in pediatric patients include cardiomyopathy and postheart transplant rejection surveillance. There have been few reports of the use of the internal jugular venous approach for right ventricular EMB in pediatric patients. In this study, we report our experience with 100 consecutive EMBs in pediatric patients using this approach. Indications for EMB were cardiomyopathy of unknown etiology in four patients, adriamycin cardiomyopathy in three patients, postheart transplant rejection surveillance in five patients, right ventricular outflow tract tumors in one patient, and sustained ventricular tachycardia in one patient. Histologic diagnoses of biopsy specimens included interstitial fibrosis, vasculopathy, hypertrophy, anthracycline cardiotoxicity, and various degrees of allograft rejection. All EMBs were performed successfully and without complications. We conclude that right ventricular EMB using the right internal jugular venous approach can be performed safely and successfully in pediatric patients as young as 2 months of age and repeatedly in patients as young as 8 years old.

Arrhythmias after cardiac transplantation

The etiology and clinical significance of sustained arrhythmias, and atrial and ventricular premature complexes (APCs and VPCs, respectively) after heart transplantation are controversial. Fifty adult recipients surviving >2 weeks were studied by continuous telemetry while in the hospital and by ambulatory electrocardiographic monitoring at 2, 4, 6, 12 and 24 weeks after transplantation. The median APC frequency was greater among subjects who experienced allograft rejection in the early postoperative period (0.7/hour, range 0 to 23) than among those who did not (0.2/hour, range 0 to 10.4) (p = 0.04). The APC frequency in all subjects decreased from 0.25/hour (range 0 to 23) early to 0/hour (0 to 14) later (p = 0.04). Atrial flutter was the most frequent sustained arrhythmia; it was recorded in 5 of 21 rejectors and in 1 of 29 nonrejectors (p = 0.04), and 11 of 16 episodes (69%) were related to acute rejection temporally. VPCs were recorded in all patients early after transplantation, but the median frequency subsequently decreased from 4.6/hour (range 0.5 to 470) early to 1.25/hour (range 0 to 225) later (p < 0.001). VPC frequency was unrelated to rejection. Sustained ventricular tachycardia was recorded once and was caused by the proarrhythmic effect of flecainide. Thus, APCs and VPCs occur frequently after transplantation. Frequent APCs are associated with rejection, whereas the main determinant of VPC frequency is time after transplantation. Atrial flutter is closely associated with rejection and should be regarded as an indication for endomyocardial biopsy. Ventricular tachycardia occurs seldom, and in this study was due to proarrhythmic drug effects.

Intracavitary Cardiac Melanoma Diagnosed by Endomyocardial Left Ventricular Biopsy

The ability to make direct, in vivo histopathologic diagnoses of myocardial diseases by transcatheter endomyocardial biopsy is an intriguing concept. In recent years, the indications for endomyocardial biopsy have expanded from the detection of cardiac transplant rejection to include a wide range of cardiac disorders, 1 Nippoldt TB Edwards WD Holmes DR Jr Reeder GS Hartzler CO Smith HC Right ventricular endomyocardial biopsy: clinicopathologic correlates in 100 consecutive patients. Mayo Clin Proc. 1982; 57: 407-418 PubMed Google Scholar for example, myocarditis, amyloid, sarcoidosis, and hemochromatosis. In the hands of experienced operators, myocardial biopsy techniques of either the right 1 Nippoldt TB Edwards WD Holmes DR Jr Reeder GS Hartzler CO Smith HC Right ventricular endomyocardial biopsy: clinicopathologic correlates in 100 consecutive patients. Mayo Clin Proc. 1982; 57: 407-418 PubMed Google Scholar or the left 2 Brooksby IAB Jenkins BS Davies MJ Swanton RH Coltart DJ Webb-Peploe MM. Left ventricular endomyocardial biopsy I: description and evaluation of the technique. Cathet Cardiovasc Diagn. 1977; 3: 115-121 Crossref PubMed Scopus (10) Google Scholar ventricle have a very low complication rate.