endomyocardial biopsy

ENDOMYOCARDIAL BIOPSY

Dr E Kiran KumarProfessor of Pathology

MIMS, Vizianagaram,A.P

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.

HISTORICAL ASPECTS• Open surgical 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.

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.

PREPARATION OF THE PATIENT

• 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.

TECHNIQUE• Performed via the 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.

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.

•Bioptome forceps with sheath

BIOPTOME FORCEPS

BIOPTOME FORCEPS WITH SHEATH

Tissue Processing• 4-5 biopsy 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.

INDICATIONS FOR EMB Most common indications are-1) To evaluate unexplained CCF 2) To diagnose myocarditis3) Constrictive v/s Restrictive CMPs4) To diagnose transplant rejection5) To evaluate drug

(anthracycline,herceptin,doxorubicin ) toxicity6) 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.” ##

INDICATIONS (cont’d)• Less common 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.

TISSUE EVALUATION• Major limitation- 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.

PROBLEMS DURING INTERPRETATION

• Sampling error-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)

COMPLICATIONSPERFORATION – CLINICAL PERFORATION

(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.

TRANSPLANT REJECTION-GRADING

TRANSPLANT REJECTION-GR 3B

TRANSPLANT REJECTION- GR3B

TRANSPLANT REJECTION GR 3A

TRANSPLANT REJECTION GR- 4

CMV INFECTION IN ALLOGRAFT

PREVIOUS BIOPSY SITE AND QUILTY EFFECT

MYOCARDITIS

HEMOCHROMATOSIS

DRUG TOXICITY

DOXORUBICIN TOXICITY

DILATED CMP

DILATED CMP

DILATED CMP- HP VIEW

DILATED CMP- MASSON’S TRICHROME STAIN

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).

MYOCARDITIS

MYOCARDITIS- HP VIEW

GIANT CELL MYOCARDITIS

GIANT CELL MYOCARDITIS-HP VIEW

EOSINOPHILIC MYOCARDITIS

CARDIAC AMYLOIDOSIS

CARDIAC AMYLOIDOSIS- CRYSTAL VIOLET STAIN

CARDIAC AMYLOIDOSIS- THIOFLAVIN T STAINING

CARDIAC AMYLOIDOSIS- BLOOD VESSELS

RESTRICTIVE CMP

RESTRICTIVE CMP- MASSON’S TRICHROME

STAIN

SARCOIDOSIS OF HEART- NON CASEATING

GRANULOMA

TUBERCULOMA HEART- CASEOUS NECROSIS

GLYCOGEN STORAGE DISEASE

##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.

RESOURCE MATERIAL1)Silverberg’s –principles and 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 Pathology5) Anderson’s - Pathology6) Internet -Cardiology and pathology journal

websites.