Elsevier

Cardiovascular Pathology

Volume 21, Issue 4, July–August 2012, Pages 245-274
Cardiovascular Pathology

Original Article
2011 Consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology

https://doi.org/10.1016/j.carpath.2011.10.001Get rights and content

Abstract

The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims:

  • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization

  • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis

  • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers.

Introduction

Endomyocardial biopsy (EMB) is a commonly performed procedure for the evaluation of cardiac tissue for transplant monitoring [1], [2], myocarditis [3], [4], [5], drug toxicity, cardiomyopathy (CMP) [3], [6], [7], [8], arrhythmia [9], [10], [11], [12], [13], [14], and secondary cardiac involvement by systemic diseases [8], and for the diagnosis of cardiac masses [15], [16], [17], [18], [19], [20], [21]. Others have highlighted EMB utility from prognostic–therapeutic [22], [23], [24] and pathogenetic view points [25].

Pathologists should assume responsibility for providing input concerning the utility of the cardiac biopsy for specific diseases and provide guidance for tissue triage and standards of morphologic evaluation [26]. This implies considering both the recent developments in myocardial and viral molecular biology and advances in imaging, electrophysiology, and genetics, and understanding how these techniques can complement traditional histopathology. The invaluable expertise of the pathologist in morphological tissue assessment may be essential in outlining appropriate diagnostic strategies in collaboration with clinicians, imagers, molecular biologists, and geneticists.

Referral of the tissue to expert pathologists and molecular biologists is warranted in many cases, given the complexity of the diagnostic tests.

Moreover, pathologists should endeavor to use uniform reference criteria and language in their reports, including:

  • degrees of diagnostic certainty: for example, certain–definite, probable, possible, nonspecific;

  • biopsy sample adequacy evaluation: for example, optimal, suboptimal.

These guidelines should be viewed as recommendations and not as mandatory requirements. They represent an overall consensus of the committee members and the opinions expressed are not necessarily those of all members of the Association for European Cardiovascular Pathology and/or the Society for Cardiovascular Pathology.

Section snippets

Recommendations, limits, and precautions

The modern view of diagnostic EMB requires the pathologist to have specific professional training [27], use accurate specimen processing [28], and support when warranted the traditional histological examination with histochemical, immunohistochemical (IHC), molecular, or ultrastructural tests (Table 1, Table 2) [24], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45] and apply standardized diagnostic histopathologic criteria to minimize EMB

Techniques and risks

EMB involves percutaneous insertion into the heart of a fluoroscopically or ultrasound-directed sheath, which allows safe and rapid insertion of the bioptome and facilitates obtaining multiple specimens.

Bioptic samples can be taken from the right ventricle, via the venous route through jugular, subclavian, or femoral veins, or from the left ventricle with transseptal puncture or by direct access through a peripheral artery, usually the femoral or brachial artery [5], [54], [55]. For better

Patient selection and clinical indications

Considering the cost–benefit ratio and possible procedural risks, careful patient selection is appropriate [24], using these criteria:

  • 1.

    Clinical setting: EMB should be considered in the context of a sequential diagnostic process, after other appropriate basic clinical–instrumental tests have excluded various diseases and focused on the possible diagnoses [26], [64];

  • 2.

    EMB effects on patient clinical management [26], [38], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74]:

  • obtain a definite

General sampling and handling

Pathological analysis of EMB is complex and requires standard protocols [26], [75]. Therefore, it is vital that the pathologist be provided with clinical information as an aid for diagnosis and to guide the most appropriate technical choices.

Grading/evidence of recommendation

Existing recommendations face limitations since, at present, they are not supported by controlled and randomized clinical studies [26], [64]. Only control–case record series; registries; single-center case records, often limited in number; and expert opinions are available, and moreover, the majority of publications are pathological diagnosis focused.

A cardiologist should not perform EMB “in the dark,” but only after consideration of the clinical presentation suggests a possible diagnosis and

Evidence of recommendation: S

Myocarditis is an inflammatory disease of the myocardium associated with cardiac dysfunction. Three forms of inflammatory CMP are recognized: infectious, autoimmune, and idiopathic. Due to the variable clinical manifestation from latent to very severe clinical forms, such as acute congestive heart failure, life-threatening arrhythmias, and sudden death, the prevalence of myocarditis is still unknown and probably underestimated. In spite of the development of various diagnostic modalities, early

Conclusion

EMB is a common procedure for the evaluation of cardiac tissue for transplant monitoring, myocarditis, drug toxicity, CMPs, arrhythmia, secondary cardiac involvement by systemic diseases, and cardiac masses. It is the gold standard for the diagnosis of cardiac rejection, myocarditis, and infiltrative/storage disorders and can be crucial for differential diagnosis in heart failure and ventricular arrhythmias. Its role in differential diagnosis, i.e., in excluding other diseases, should be

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