Endomyocardial Biopsy
Mauro Moscucci, MD, MBA
INTRODUCTION
The development of new imaging modalities and particularly of magnetic resonance imaging has provided new tools for the diagnosis of disorders of the myocardium. Despite these advancements, the diagnosis of myocardial diseases continues to be challenging. Endomyocardial biopsy can allow a more precise characterization of the underlying primary myocardial pathology in several diseases, and it remains the gold standard for the assessment of transplant rejection. In this chapter we will review available devices, biopsy techniques and complications, indications for endomyocardial biopsy in the current era, and its utility and findings in specific disease states.
Bioptomes
After the first biopsy performed by Weinberg, Fell, and Lynfield in 1958 through an incision in the left intercostal space at the costochondral junction,1 Sutton and Sutton in 1960 reported their experience with percutaneous myocardial biopsy performed at the left ventricular apex or at the left costosternal junction. They used a Terry needle, which was made highly flexible by a modified thin wall (FIGURE 16.1).2 Timmis and colleagues in 1965 reported their experience with the use of a modified Silverman needle and Menghini needle (FIGURE 16.1).3 The concept of percutaneous insertion of a heart biopsy needle through the right external or internal jugular vein was introduced by Bulloch4 in 1965. The technique involved positioning in the right ventricle a 16-gauge, 50-cm-long curved shaft advanced through a largebore radiopaque catheter. Cutting blades were then advanced through the metal shaft.
In 1962, Sakakibara and Konno introduced the Konno biopsy technique and the Konno bioptome.5 The device included a 100-cm shaft ending with 2 sharpened cups, connected to a wire (FIGURES 16.2 and 16.3). A sliding assembly attached to the proximal end of the catheter activated the wire, and the operation of the wire would open and close the sharpened cups. The operation of the cups allowed “biting” biopsy samples. Caves modified the Konno bioptome for use through the right internal jugular vein. The modification allowed the bioptome to be inserted percutaneously, but the high profile required the use of large no-valve sheaths, which was associated with higher blood losses and the risk of air embolism during insertion and withdrawal of the bioptome. In 1972 Caves introduced the Stanford modification to the Konno bioptome (Stanford or Caves—Schulz bioptome).6,7 The Stanford bioptome was used until 1995. It was preshaped and had only 1 articulated jaw while the other jaw was fixed. It was developed specifically for right ventricular biopsy using the right internal jugular approach (FIGURE 16.4). As of today, there are several disposable and reusable bioptomes, which are available in different lengths and French sizes, with preshaped and straight tips (FIGURE 16.5). They can be used from a variety of entry sites including the internal jugular vein, the femoral vein, the subclavian vein, and the transfemoral artery approach for left ventricular biopsy.
 FIGURE 16.1 A, Modified Terry biopsy needle used by Sutton and Sutton (1.1 mm inside diameter). B, Standard Vim-Silverman needle (14 gauge Xl10 mm) fitted with Luer-lock adapter to limit penetration of the cutting piece 1.1 cm beyond the trochar and to serve as an electrode connector for electrocardiographic epicardial sensing. C, Menghini biopsy needle (1.6 × 70 mm) and syringe mounted with a special autoclavable platinum ECG electrode extension, which served also to limit penetration of the needle. A, Modified with permission from Sutton DC, Sutton GC. Needle biopsy of the human ventricular myocardium: review of 54 consecutive cases. Am Heart J. 1960;60:364-370; B, Modified with permission from Timmis GC, Gordon S, Baron RH, Brough AJ. Percutaneous myocardial biopsy. Am Heart J. 1965;70(4):499-504; C, Modified with permission from Timmis GC, Gordon S, Baron RH, Brough AJ. Percutaneous myocardial biopsy. Am Heart J. 1965;70(4):499-504. |
 FIGURE 16.2 Instrument for endomyocardial biopsy devised by Konno. Reproduced with permission from Sakakibara S, Konno S. Endomyocardial biopsy. Jpn Heart J. 1962;3:537-543. |
 FIGURE 16.3 A, Closed top edges of the Konno bioptome. B, Opened top edges of the instrument. Reproduced with permission from Sakakibara S, Konno S. Endomyocardial biopsy. Jpn Heart J. 1962;3:537-543. |
 FIGURE 16.4 Stanford (Caves-Schulz) bioptome. The surgical clamp drives a control wire to which it is connected via 2 adjustable nuts, thereby controlling the position of the single mobile jaw at the distal end of the catheter. From Baim DS. Grossman’s Cardiac Catheterization, Angiography, and Intervention. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. |
 FIGURE 16.5 Single-Use disposable Novatome Bioptome made by Scholten Surgical Instruments, Inc. A. 50 cm and B. 100 cm lengths. Courtesy of Scholten Surgical Instruments, Inc., Lodi, California. |
VASCULAR APPROACH
The right internal jugular approach has been the traditional approach for right ventricular biopsy, with either a preshaped bioptome or a preformed sheath. During the procedures, the patient’s electrocardiogram, pulse oximetry, and blood pressure are monitored continuously.
The internal jugular vein is located lateral to the carotid artery, within the triangle formed by the sternal and clavicular head of the sternocleidomastoid muscle and the clavicle (FIGURE 16.6). Ultrasound’s guidance and the use of micropuncture kits enhance the safety of vascular access (FIGURES 16.7 and 16.8). With the preshaped bioptome, the direction of the bioptome tip is concordant with the position of the handle. The preshaped bioptome is inserted with the tip pointing toward the anterior wall of the right atrium. It is advanced across the tricuspid valve and toward the intraventricular septum with a progressive 180° counterclockwise rotation (FIGURE 16.9). Other approaches that have been used include the left internal jugular vein with a flexible sheath and the right femoral vein with a preformed sheath or a guiding catheter (FIGURES 16.10 and 16.11). Owing to the vascular anatomy, the subclavian vein is not a preferred approach, but it can be used if needed with long sheaths (FIGURE 16.12).8 Left ventricular biopsy can be performed via the femoral artery or radial artery approach using either a preformed sheath or a guiding catheter, and it might have additional diagnostic value in patients with cardiomyopathies and clinically preserved right ventricular function.9
 FIGURE 16.6 Regional anatomy for internal jugular puncture. With the patients head rotated to the left, the sternal notch, clavicle, as well as the sternal and clavicular heads of the sternocleidomastoid muscle are identified. A skin nick is made between the 2 heads of this muscle, and 2 fingerbreadths above the top of the clavicle (near the top of the anterior triangle). The needle is inserted at an angle of 30°-40° from vertical, at 20°-30° right of sagittal, aiming the needle away from the more medially located carotid artery. Reproduced with permission from Chaparro SV, Moscucci M. Endomyocardial biopsy. In: Moscucci M, ed. Grossman & Baim’s Cardiac Catheterization Angiography and Intervention. Philadelphia: Lippincott Williams and Wilkins; 2014. |
 FIGURE 16.7 Ultrasound guidance can facilitate and increase the safety of vascular access. The image on the left side shows the carotid artery (c) and the internal jugular vein (ij) at rest, while the image on the right shows the carotid artery (c) and the distended internal jugular vein (ij) during Valsalva maneuver. Reproduced with permission from Chaparro SV, Moscucci M. Endomyocardial biopsy. In: Moscucci M, ed. Grossman & Baim’s Cardiac Catheterization Angiography and Intervention. Philadelphia: Lippincott Williams and Wilkins; 2014. |
 FIGURE 16.8 Micropuncture apparatus: 21-gauge micro-puncture needle, 0.018-inch guidewire, 5 Fr guided sheath, and obturator. Glide access® System Photo – © 2018 Terumo Medical Corporation. |
 FIGURE 16.9 A-F, Cineangiographic frames obtained during right ventricular endomyocardial biopsy using the Stanford bioptome. From left to right, the top rows shows the bioptome against the right atrial wall, against the ventricular septum, withdrawn slightly with jaws open and then against the septum with jaws closed. In the bottom row, the jaws are closed and the bioptome is withdrawn with the sample contained. Reproduced with permission from Chaparro SV, Moscucci M. Endomyocardial biopsy. In: Moscucci M, ed. Grossman & Baim’s Cardiac Catheterization Angiography and Intervention. Philadelphia: Lippincott Williams and Wilkins; 2014. |
 FIGURE 16.10 Right ventricular biopsy from the femoral vein using a double-angulated sheath. Left, in the left anterior oblique projection, contrast injection demonstrates how the terminal sheath curve orients the tip towards the septum (IVS) and away from the free wall (FW). Right, in the right anterior oblique position, contrast injection demonstrates a suitable position about mid-way from the atrial-ventricular groove to the apex. Reproduced with permission from Chaparro SV, Moscucci M. Endomyocardial biopsy. In: Moscucci M, ed. Grossman & Baim’s Cardiac Catheterization Angiography and Intervention. Philadelphia: Lippincott Williams and Wilkins; 2014. |
 FIGURE 16.11 Endomyocardial biopsy via the femoral vein using a long, curved sheath. A, Left anterior oblique (LAO), (B) anteroposterior (AP), and (C) right anterior oblique (RAO) views of sheath position in the right ventricle. Reproduced with permission from: Naderi N, et al. Endomyocardial Biopsy via the Femoral Vein Using a Long, Curved Sheath. Transplant Proc. 2017;49(6):1436-1439. |
 FIGURE 16.12 Top panel. Seven French 35 cm sheath with multipurpose—a curve, side port extension with 3-way stopcock and dilator. Bottom panel: (A) sheath course from the right subclavian approach (posterior anterior projection). B, sheath positioned in the right ventricle from the right subclavian approach (posterior-anterior projection). Modified with permission from Corley DD, Strickman N. Alternative approaches to right ventricular biopsy. Cathet Cardiovasc Diagn. 1994;31:236-239. |
ECHOCARDIOGRAPHY-GUIDED BIOPSY
Endomyocardial biopsies are usually performed under fluoroscopic guidance. More recently, echocardiography (transthoracic, intracardiac and transesophageal) has emerged as an additional imaging modality to guide endomyocardial biopsy.10,11,12,13,14,15,16 It is most commonly used as an adjunct to fluoroscopy, particularly during biopsy of intracardiac masses,17,18,19,20,21 but it has also been used as the only imaging modality (FIGURES 16.12 and 16.13).
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