Abstract
Although new imaging techniques for characterizing the myocardium show promise, endomyocardial biopsy (EMB) remains the gold standard for the diagnosis of allograft rejection following cardiac transplantation and other myocardial diseases. The equipment required for EMB is easily obtainable and likely available in most well-equipped catheter laboratories. This procedure can be performed safely with a low incidence of complications by experienced operators at cardiac centres with a large volume of patients.
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Acknowledgements
We thank our technologists Dariusz Mroczek and Renato Prosio for providing images and videos.
The bioptomes commonly employed are single use. There are two different types of bioptomes available. One type has a pre-shaped distal end and the other has a flexible shaft and unshaped distal end. In this picture, we show a 50 cm long 5.5 fr flexible bioptome (Cordis®) that may be used in a 6F 40 cm long pre-shaped Flexor® Check-Flo® Introducer® (Cook®). This combination can be used to perform biopsies from the jugular vein. In infants and small children, this combination could be long enough to be used from the femoral vein
Modern bioptomes have a 3-pull ring handle with a spring so that samples can be held easily while being removed. The central ring of the handle can rotate to accommodate any hand position. The two anterior rings are grabbed with the forefinger and the middle finger, and the posterior ring with the thumb. The jaws of the bioptomes are opened by pushing the two anterior rings forward; pulling them back to the posterior ring closes the jaws
In these pictures, we show a bioptome with forceps completely open (Panel a) and closed (Panel b). Please note that the bioptome has sharpened cusps designed to pinch rather than to cut the myocardial muscle
A standard guidewire has been placed in a distal pulmonary artery branch via a standard end-hole catheter from an internal jugular vein approach (Panel a). The long sheath is advanced gently over the wire (Panel b). The wire and dilator are then removed, leaving the tip of the long sheath in the right ventricle
Panels (a and b) show the position of a long sheath in the right ventricle which was inserted via the femoral vein in anteroposterior and lateral projections, respectively. The samples should be taken from the subapical interventricular septum to avoid cardiac perforation
Panels (a and b) show in anteroposterior and lateral projections the open jaws of the bioptome, facing the interventricular septum and ready to pinch the muscle
Panels (a and b) show in anteroposterior and lateral projections, respectively, the bioptome with the jaws closed, immediately after the sample has be taken. The bioptome can now be retrieved from the long sheath
Panel (a and b) show in anteroposterior projection the bioptome inserted from the jugular vein with the jaws open and closed, respectively
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The long sheath is advanced from the jugular vein over a wire previously placed in the distal pulmonary artery. The wire and dilator are then removed, leaving the long sheath in the right ventricle. Good guidewire position will allow for smooth advancement of the sheath into the right ventricle. In patients after cardiac transplantation, difficulties in advancing the long sheath through the superior vena cava may suggest stenosis at the anastomotic site (MOV 4949 kb)
Before the insertion of the flexible bioptome through the long sheath, it may be useful to curve the distal end of the bioptome to direct the tip towards the interventricular septum. The bioptome should be advanced under fluoroscopic surveillance generally in anteroposterior and 90° lateral (when biplane is used) views. Care should be taken to keep the end of the long sheath stable as the bioptome is advanced. When the tip of the bioptome is near the end of the long sheath, the bioptome handles should be pushed forward, allowing the jaws to open as the tip is carefully advanced out of the long sheath. Once the jaws of the bioptome are seen to be fully open, the bioptome should be advanced slowly to engage the right ventricular myocardium. When the bioptome jaws are engaged in the myocardium, mild resistance may be felt and premature ventricular beats may be provoked. There is also a change in the curve of the bioptome/long sheath due to the mild pressure that is applied. Too much pressure may result in myocardial perforation; however, the jaws of the bioptome must remain engaged with the myocardium to obtain a good sample. The handles of the bioptome are then brought together, closing the jaws and ‘pinching’ off a sample of tissue (MOV 9484 kb)
The bioptome may then be retrieved, always keeping the jaws closed. Mild resistance may be felt on retrieval as the jaws ‘pinch off’ a sample. Care should be taken to maintain a stable position of the long sheath. Advancing the long sheath gently as the bioptome is retrieved may help maintain a good position in the RV (MOV 991 kb)
Samples should be taken from different parts of the interventricular septum. This may reduce the risk of myocardial perforation from repeated sampling at the same site, as well as increase the chance of obtaining a diagnosis in disease processes that do not affect the myocardium uniformly. Repositioning the long sheath safely can be achieved by advancing a balloon catheter (i.e. Berman catheter) through the long sheath (MOV 1606 kb)
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Marini, D., Wan, A. (2019). Endomyocardial Biopsies. In: Butera, G., Chessa, M., Eicken, A., Thomson, J.D. (eds) Atlas of Cardiac Catheterization for Congenital Heart Disease. Springer, Cham. https://doi.org/10.1007/978-3-319-72443-0_34
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DOI: https://doi.org/10.1007/978-3-319-72443-0_34
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