There are three commonly utilized access sites for EMB. The most commonly used route is the right internal jugular vein. In this technique, the patient is prepped and draped in a sterile fashion. Ultrasonography, although not absolutely necessary, is commonly utilized for obtaining access to the vein. The venous sheath is then inserted over a wire. Once the sheath is flushed, the bioptome is inserted through the venous sheath under fluoroscopic guidance and advanced superiorly and posteriorly towards the interventricular septum. Once positioning is verified, the bioptome jaws are opened (Fig. 35.2), advanced towards the septum, and closed. The bioptome is pulled back gently at this time. Once the bioptome is free, it is pulled out of the venous sheath and the biopsied tissue is removed from the forceps and the procedure is repeated over again. Occasionally, echocardiographic guidance may be utilized to assist in bioptome positioning while performing EMB.

Other commonly used access sites include the subclavian/axillary vein and the femoral venous approach. When the femoral vein is used, a longer bioptome is used (105 cm) which is introduced through a long 7F venous sheath. Internal jugular and subclavian approaches utilize the standard 50 cm bioptome introduced through a standard 7F 11 cm long venous sheath.

In rare instances, the femoral arteries could be utilized for EMB of the left ventricle.

Storage of the sample is dictated by the clinical question to be answered. A minimum of 5 right ventricular samples should be obtained if possible. Standard histological preparation using paraffin embedding, sectioning and staining can be used in the diagnosis of allograft rejection, myocarditis or amyloidosis. Polymerase chain reaction for the detection of viruses can be performed on paraffin-embedded tissue although the sensitivity is higher when performed on liquid nitrogen frozen tissue.