endomyocardial biopsy
TRANSCRIPT
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ENDOMYOCARDIAL BIOPSY
Dr E Kiran KumarProfessor of Pathology
MIMS, Vizianagaram,A.P
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What is EMB ?• Endomyocardial Biopsy(EMB) is a
technique by which heart tissue is sampled from the pts with suspected cardiac disorders for microscopic diagnosis and evaluation of the lesions.
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HISTORICAL ASPECTS• Open surgical biopsies of heart-1950’s,
followed by needle bx using modified vim-silverman’s needle through thoracotomy/trans-thoracic approach- complications like pneumothorax/ cardiac tamponade. .
• The first trans-venous biopsy fx- KONNO- SAKAKIBARA BIOPTOME- Japan-1962.
• Modified bioptome- CAVES-SCHULTZ-STANFORD bioptome- Stanford-1972.
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HISTORICAL ASPECTS (cont’d)
• Further modifications in catheter design- sheathing and increased flexibility and easy manouverability, e.g Modified Cordis Bioptome.
• Novel-shaped long-neck sheath for endomyocardial biopsy through the internal jugular approach- reduces trauma and provides stability for the bioptome forceps,limits radiation exposure.
• EMB –Initially performed via the “internal jugular vein”, later- femoral venous approach is used after the advent of long and flexible bioptomes.
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PREPARATION OF THE PATIENT
• Routine lab tests, an ECG and a chest x-ray.
• Pt should have nothing to eat or drink, 6 hrs before the procedure, except the medication.
• Done in Cardiac Catheterization lab.• Anaesthetic medication used-
novocaine.
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TECHNIQUE• Performed via the transvascular approach
and is done usually at the time of cardiac catheterization.
• Right ventricle is preferred as it is easier and safer to biopsy this chamber.
• Rt ventricle is the representative site in diffuse diseases. Lt ventricle is preferred in sarcoidosis and done via arterial approach.
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Technique (cont’d) A flexible, plastic tube called a “sheath” is inserted into
the vein in the neck or groin, followed by insertion of “pulmonary artery catheter” into the rt side of heart ( under fluoroscopic guidance), which measures the pressures inside the heart. Then the catheter is removed.
• Then BIOPTOME is guided through the sheath into the heart. Biopsy forceps can easily be taken upto the apical portion of RVS.3-4 tissue samples of 2-3 mm size are obtained.Then the bioptome and sheath are removed.
• Flexible, disposable bioptomes- presently available.• Availability of catheters and bioptome forceps of
different sizes and designs - Apical curvature- for easy sampling and grip on the tissue.
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•Bioptome forceps with sheath
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BIOPTOME FORCEPS
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BIOPTOME FORCEPS WITH SHEATH
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Tissue Processing• 4-5 biopsy fragments are processed
routinely and 1 fragment for EM exam.• Transplant biopsies- if vascular
rejection is suspected, 1 fragment is frozen for immunofluorescence.
• Anthracycline, Chloroquine and Amiodarone toxicity- All fragments are processed for EM.
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INDICATIONS FOR EMB Most common indications are-1) To evaluate unexplained CCF 2) To diagnose myocarditis3) Constrictive v/s Restrictive CMPs4) To diagnose transplant rejection5) To evaluate drug
(anthracycline,herceptin,doxorubicin ) toxicity6) To investigate effects of anabolic steroids,
thalassemia and HIV cardiomyopathy).
## “EMB is the most useful tool for the diagnosis and monitoring of cardiac allograft rejection after cardiac transplantation.” ##
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INDICATIONS (cont’d)• Less common indications are 1) To investigate idiopathic
arrythmias 2) Biopsies of neoplasms .One impt indication for Lt ventr bx-
“suspected cardiac sarcoidosis”- Involves lt vent > rt vent – An arterial approach is reqd for lt vent biopsy.
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TISSUE EVALUATION• Major limitation- SAMPLING• Bioptome is guided towards the apex of the
right ventricle, yielding tissue from the ventricular septum or right ventricular wall.
• FOCAL INVOLVEMENT -Inflamm and Infiltr diseases like myocarditis, haemochromatosis, sarcoidosis and amyloidosis . Hence easily MISSED by biopsy.
• Hence SERIAL SECTIONING of multiple sections through the block required.
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PROBLEMS DURING INTERPRETATION
• Sampling error-due to focal nature of disease (e.g. myocarditis)
• Crush artifacts-mech trauma• Contraction bands(AMI, Mech trauma)• Focal interstitial fibrosis (non- specific
finding)• Interstitial mesenchymal cells closely
resemble lymphocytes.• Endocardial thickening( non specific finding)• Adipose tissue (normal in rt ventr biopsy)
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COMPLICATIONSPERFORATION – CLINICAL PERFORATION
(chest pain and pericardial effusion as judged by transthoracic echocardiography or TEE) and ``NEAR PERFORATION'' (epicardial fat in specimens.
• The risk of perforation can be reduced by using a specially curved sheath to guide the biopsy forceps toward the interventricular septum.
• Others- mostly in pediatric age group- Arrythmias(AF/VF), Pneumothorax and Haemopericardium.
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TRANSPLANT REJECTION-GRADING
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TRANSPLANT REJECTION-GR 3B
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TRANSPLANT REJECTION- GR3B
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TRANSPLANT REJECTION GR 3A
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TRANSPLANT REJECTION GR- 4
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CMV INFECTION IN ALLOGRAFT
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PREVIOUS BIOPSY SITE AND QUILTY EFFECT
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MYOCARDITIS
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HEMOCHROMATOSIS
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DRUG TOXICITY
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DOXORUBICIN TOXICITY
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DILATED CMP
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DILATED CMP
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DILATED CMP- HP VIEW
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DILATED CMP- MASSON’S TRICHROME STAIN
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Figure 1 (A) Biopsy from a 45 year old woman with dilated cardiomyopathy. Note the endocardial fibrosis, myocyte hypertrophy, myocyte nuclei, and moderate interstitial fibrosis (haematoxylin and
eosin staining; original magnification, x10). (B) Elastic trichrome stain of the same case showing thickened fibrous endocardium with
considerable interstitial fibrosis (original magnification, x10).
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MYOCARDITIS
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MYOCARDITIS- HP VIEW
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GIANT CELL MYOCARDITIS
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GIANT CELL MYOCARDITIS-HP VIEW
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EOSINOPHILIC MYOCARDITIS
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CARDIAC AMYLOIDOSIS
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CARDIAC AMYLOIDOSIS- CRYSTAL VIOLET STAIN
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CARDIAC AMYLOIDOSIS- THIOFLAVIN T STAINING
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CARDIAC AMYLOIDOSIS- BLOOD VESSELS
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RESTRICTIVE CMP
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RESTRICTIVE CMP- MASSON’S TRICHROME
STAIN
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SARCOIDOSIS OF HEART- NON CASEATING
GRANULOMA
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TUBERCULOMA HEART- CASEOUS NECROSIS
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GLYCOGEN STORAGE DISEASE
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##TAKE HOME MESSAGE ##
• Endomyocardial biopsy is an inevitable and an efficient investigative tool for assesment of rejection grading of the allograft after CARDIAC TRANSPLANTAION.
• There is a significant REDUCTION in the incidence of complications of the procedure, due to the NEWER MODIFICATIONS in the DESIGNING of the sheath and bioptome forceps.
• Done in CARDIAC CATHETERISATION LAB, in the presence of interventional cardiologist, and under FLUOROSCOPIC guidance.
• Sampled heart tissue can be subjected to ROUTINE TISSUE PROCESSING for HPE, ANCILLIARY techniques like IHC, Enzyme Histochemistry, Special Stains, ,EM, Molecular Phenotyping ,RT- PCR techniques for detection of viral nuclei acids,etc.
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RESOURCE MATERIAL1)Silverberg’s –principles and practice of
surgical pathology and cytopathology.2)Chopra’s-Text book of cardiovascular
pathology.3)Sternberg’s –Diagnostic surgical pathology.4)Weidner’s – Modern Surgical Pathology5) Anderson’s - Pathology6) Internet -Cardiology and pathology journal
websites.