Endomyocardial Biopsy in Cardiovascular Disease

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


January 06, 2014

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Take-Home Points

Dr Gersh: So Les, can you give us a few take-home points?

Dr Cooper: If you encounter a patient with acute dilated cardiomyopathy who is failing despite your best efforts and if that patient has complications of ventricular tachycardia or heart block, if you can't perform a biopsy at your institution, our scientific statement recommends transfer to an institution where that biopsy can be performed expediently. The second is getting expert cardiac pathology review. If you don't have access to pathologists with expertise locally, do not hesitate to send the slides to a center of excellence regionally where those slides can be read.

Dr Gersh: What about the young man with a short history who is doing okay? He comes in with heart failure and doesn't immediately improve. If his ejection fraction goes from 30% to 50%, the pressure is off. But he is not fulminant, he doesn't have VT, he doesn't have heart block, but he has unexplained heart failure of a short duration. I have sent those patients for biopsy. I don't see what the downside is.

Dr Cooper: The downside is the cost and risk of the biopsy. Current guidelines do not recommend the routine use of heart biopsy for the evaluation of heart failure, and based on the low yield in an unselected population, that's probably correct.

Dr Gersh: In that young patient with a four-week history, do you think that's still a low yield?

Dr Cooper: The number of times that you will find a diagnosis that will change your management is low, not zero, but quite low. That is currently what the guidelines say. It's currently my clinical practice too. In the patients I see—and I have a large heart-failure practice—I biopsy about 10%.

Dr Gersh: That's higher than most, but you are seeing a very selected group, I suspect.

Dr Cooper: I get a lot of referrals.

Dr Gersh: So in that patient with a four-week history, if he was doing okay clinically, you would hold off?

Dr Cooper: Yes, I would. I would be sure to repeat the clinical evaluation and a functional assessment within a month or two to make sure that he is not deteriorating, but if he is clinically stable to improving and his heart function is stable, then I would not proceed with a biopsy.

Dr Gersh: Two final, quick questions. Do you ever use immunosuppressive therapy without biopsy evidence?

Dr Cooper: If there is a strong suspicion for giant-cell myocarditis with the clinical scenario that I described, I will give a bolus of methylprednisolone while we wait for the biopsy to come back, but I don't give long-term immunosuppression without biopsy evidence.

Dr Gersh: Lastly, a patient with pericarditis—most people with pericarditis have myopericarditis, right?

Dr Cooper: Right.

Dr Gersh: So if the patient comes in with pericarditis and global left ventricular dysfunction or even regional left ventricular dysfunction that suggests myopericarditis and troponins are elevated, would you biopsy?

Dr Cooper: No. I don't biopsy myopericarditis because overall the outcome is excellent. However, you should avoid colchicine or nonsteroidal anti-inflammatory drugs if there is substantial left ventricle dysfunction. Most of those patients have normal or near normal left ventricle function and colchicine is safe. But in the patients who have more myocardial dysfunction, we do not use colchicine.

Dr Gersh: That's a great practical take-home point and thank you, Les.

Dr Cooper: You're welcome. Great to be here.


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