COMMENTARY

Endomyocardial Biopsy in Cardiovascular Disease

Bernard J Gersh, MB, ChB, DPhil; Leslie T Cooper, Jr, MD

Disclosures

January 06, 2014

Editorial Collaboration

Medscape &

In This Article

Who Else Might Need a Biopsy?

Dr Gersh: You have described the class 1 indications for biopsy, but my understanding is that there are a number of gray areas where it's much more controversial.

Dr Cooper: That's correct, and an area that has gathered a lot of interest recently is chronic heart failure due to nonischemic cardiomyopathy that is getting worse despite guideline-based therapy.

Patients with a few years of symptoms from disease onset who are failing and headed toward transplant, despite your best attempt at neurohumoral inhibition, might benefit from a biopsy, and the reason is that inflammation in that setting can respond to immunosuppressive therapy, which may improve heart function.

Dr Gersh: You are suggesting doing a biopsy in people with nonischemic dilated cardiomyopathy for whatever reason who now are getting an associated myocarditis.

Dr Cooper: Correct. In some people, the injury, whether it is genetic or other problem leading to a dilated cardiomyopathy, becomes associated with inflammation. It doesn't happen all the time, and it's probably a minority of the time, but when it does, there are two trials that suggest that immunosuppressive therapy can improve function.

Dr Gersh: You are not implying that they have now developed a Coxsackie viral infection or a picornavirus infection.

Dr Cooper: No. This could be simply your body, your immune system's response to an endogenous danger signal, so you are getting the cascade of events, the toll-like activation, all the way downstream to enough cytokines to suppress your heart function; for example, patients who have inflammatory bowel disease with systemic inflammation and who develop a cardiomyopathy or patients with lupus who develop a cardiomyopathy sometimes with a pericardial effusion.

Dr Gersh: That's interesting and certainly new for me and I'm sure for some of our listeners. What about some of the other indications—for example, connective tissue diseases and inflammatory bowel disease? How common is cardiomyopathy in the setting of inflammatory bowel disease?

Dr Cooper: It's probably 1% to 2% in our experience, which is a referral experience, of course. Our practice at Mayo Clinic in Rochester has been to perform heart biopsy in the setting of suspected myocarditis in the clinical scenario of a systemic inflammatory disease. In that setting, we would change our management according to the results of biopsy to either increase or add immunosuppressive therapy if the patient had myocarditis.

Diagnosing Cardiac Sarcoidosis

Dr Gersh: Are there any other gray areas?

Dr Cooper: One of the most exciting areas that we are working on currently is the diagnosis of suspected cardiac sarcoidosis. The trouble with endomyocardial biopsy for sarcoidosis is low sensitivity.

It's a very focal process, and even in patients who have the disease confirmed eventually, 70% of the time you miss it with biopsy because of sampling error. We are now using a mapping catheter-guided biopsy, and anecdotally we are having good results identifying areas of inflammation from fractured electrograms.

Dr Gersh: You are using the NOGA mapping system [Cordis/Johnson & Johnson], or is it an electrophysiology [EP] catheter?

Dr Cooper: This is an EP catheter. I think more than one has been used.

Dr Gersh: It's important in that even in straightforward "myocarditis," it may be focal and it may be generalized. It may involve the left ventricle, and yet we biopsy from the right ventricle. There is a diminished sensitivity, so the idea of being able to tailor the biopsy forceps to where you want to go is very interesting.

Dr Cooper: And rather than use MRI, which can show areas of inflammation or scar but not in real time, today (because we don't have MRI-compatible bioptomes) this technology allows you to perform a biopsy at the same time as the electrogram.

Dr Gersh: Have you ever biopsied the left ventricle? Obviously, there is a thrombotic risk, but has that been done?

Dr Cooper: Yes, enthusiasm for left ventricular biopsy diminished 20 or so years ago after the series demonstrated a stroke risk; however, more recent data published from Europe suggest that left ventricular biopsy can be safe with appropriate levels of anticoagulation.

Dr Gersh: Have we performed it?

Dr Cooper: We have performed left ventricular biopsy at Mayo Clinic Rochester on rare occasions where only the left ventricle is involved and we truly need to make the diagnosis.

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