Endomyocardial Biopsy

EMB  - Endomyocardial Biopsy

• Widely used for surveillance of cardiac allograft rejection and unexplained ventricular dysfunction.
• Should be done in young patients with myocarditis and older patients with infiltrative cardiac disease.

Approach:
Through femiral vein or artery
Right internal jugular vein (preferred)

Biopsy samples are taken from IVS (interventrucular septum) - since RV wall is thin and can lead to perforation.

Can be guided by fluoroscopy or 2D echocardiography.
Transthoracic echo guidance is preferred.

Commonly used bioptomes:
1. Novatome
2. Argon EMB forceps
3. Bipal 7 bioptome.

Five biopsies are taken and put in isotonic saline.

Transferred to
1. 10% neutral buffered formalin - rejection, cardiomyopathy, myocarditis abd tumours

2. Zeus fixative - for IF studies for rejection  (C4d)

3. 4% glutaraldehyde - electron microscopy for drug toxicity, metaboloc or storage disease and LCDD (light chain deposition disease)

4. Snap frozen tissue in liquid nitrogen - PCR (viral myocarditis) Dystrophin (muscular dystrophy)

EMB is absolutely necessary for diagnosis of the following  conditions:
1. Anthracycline induced cardiomyopathy  - loss of myofilaments and vacuolar degeneration.
2. Cardiac allograft rejection
3. Sarcoidosis
4. Giant cell myocarditis
5. Hylereosinophilic syndrome

Complications of EMB:
IMMEDIATE:
Site hematoma
Transient RBBB
Transient arrhythmias
Tricuspid regurgitation
RV perforation -- cardiac tamponade and pericardial effusion
Occult pulmonary embolism

LATE:
Coronary artery to RV fistula formation
Severe tricuspid regurgitation