Endomyocardial Biopsy Mayo Clin Proc, October 2001, Vol 76 1030 Mayo Clin Proc. 2001;76:1030-1038 1030 © 2001 Mayo Foundation for Medical Education and Research Subspecialty Clinics: Cardiology Subspecialty Clinics: Cardiology Current Role of Endomyocardial Biopsy in the Management of Dilated Cardiomyopathy and Myocarditis LAMBERT A. WU, MD; ANDRE C. LAPEYRE III, MD; AND LESLIE T. COOPER, MD From the Division of Cardiovascular Diseases and Internal Medi- cine, Mayo Clinic, Rochester, Minn. Address reprint requests and correspondence to Leslie T. Cooper, MD, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: cooper.leslie@mayo.edu). O btaining myocardial tissue from humans initially in- volved a transthoracic needle approach, as described by Sutton et al in 1956. 1 However, in 1962, Sakakibara and Konno 2 described the procurement of endomyocardial tis- sue from the right ventricle via a transvascular approach using the Konno bioptome. The current, most widely ac- cepted approach to obtaining endomyocardial tissue is from the right ventricle through the right internal jugular vein. Although this approach is usually safe, serious com- plications, including death, may rarely occur. In this article, we present an illustrative case and then evaluate the role of the endomyocardial biopsy (EMB) in the management of dilated cardiomyopathy (DCM) and specific myocarditides. In doing so, we evaluate EMB safety and potential to impact therapy. Finally, we offer clinical guidelines for EMB that balance risk and benefit. The role of EMB may differ in pediatric patients, cardiac transplant patients, and patients with hypertrophic cardio- myopathy and idiopathic restrictive cardiomyopathy. These conditions are not discussed in this article. REPORT OF A CASE A 70-year-old woman presented to our hospital with bilat- eral lower extremity edema and dyspnea on exertion, which had increased over the last month. An adenosine Dilated cardiomyopathy is a common cause of congestive heart failure. Despite a thorough cardiovascular evalua- tion, a specific cause is frequently not found, and the disor- der then is considered idiopathic. Endomyocardial biopsy (EMB) may yield diagnostic and prognostic information in patients with idiopathic dilated cardiomyopathy; however, the yield of useful information with this procedure among patients with heart failure is low, and the risks of occa- sional cardiac perforation and death further limit its use. Recent publications in the field of myocarditis and cardio- myopathy have renewed interest in the use of EMB in select patients to diagnose specific and potentially treat- AIDS = acquired immunodeficiency syndrome; DCM = di- lated cardiomyopathy; ECG = electrocardiography; EMB = endomyocardial biopsy; GCM = giant cell myocarditis; HIV = human immunodeficiency virus; HSM = hypersensitivity myo- carditis able myocarditides; however, the role of EMB in the work- up of patients with dilated cardiomyopathy is not well defined. In this article, we discuss the risks and utility of EMB in the management of patients with dilated cardio- myopathy and specific myocarditides. Mayo Clin Proc. 2001;76:1030-1038 sestamibi test revealed normal perfusion. The patient had minimally contributory medical history with no history of heart disease. Cardiac risk factors included hypertension and a remote history of cigarette use. The patient’s only medication was a daily multivitamin. On physical examination, the patient was afebrile with a normal blood pressure and heart rate. Jugular venous pres- sure was normal, and cardiac examination showed a regu- lar rhythm and normal rate. Auscultation revealed bilateral inspiratory rales. The abdomen was not distended and showed no signs of organomegaly. The lower extremities showed bilateral pitting edema. Electrocardiography (ECG) showed a normal sinus rhythm, normal axis, and occasional premature ventricular complexes. Chest radiography showed a slightly enlarged heart with increased interstitial edema. An echocardiogram demonstrated a moderately enlarged left ventricle with se- verely impaired global systolic function. The left ventricu- lar ejection fraction was calculated at 21%. Coronary angiography demonstrated normal coronary arteries. She subsequently underwent a right ventricular biopsy via the right internal jugular vein approach. After the last piece of tissue was obtained, the patient had a sudden drop in her blood pressure and became unrespon- sive. The patient was intubated, and emergent echocardiog- raphy demonstrated a large pericardial effusion, which was unable to be drained by pericardiocentesis secondary to clot formation. The cardiothoracic surgeons performed an emergent right thoracotomy. Large-volume blood loss via a tear in the right ventricular free wall was seen, and tissue friability prevented closing the tear with sutures. For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.