Electron microscopic investigation of endomyocardial biopsy samples in hypertrophy and cardiomyopathy. A semiquantitative study in 48 patients

Chronic anthracycline cardiotoxicity: haemodynamic and histopathological manifestations suggesting a restrictive endomyocardial disease

Of 38 patients referred with suspected cardiotoxicity after administration of antineoplastic drugs, 11 patients with signs of manifest or latent anthracycline cardiotoxicity were selected for heart catheterisation with endomyocardial biopsy. Ultrastructural abnormalities of the myocytes with myofibrillar loss and cytoplasmic vacuolation were present in most patients and these findings were more pronounced in biopsy specimens from the left ventricle. Surprisingly, light microscopy showed considerable fibrous thickening of the endocardium in 10 of 11 patients, primarily in the left ventricle. These morphological findings together with the echocardiographic and the haemodynamic data suggest that chronic anthracycline cardiotoxicity is a restrictive endomyocardial disease. The biochemical mechanisms responsible for endocardial fibrosis are unknown, but drug induced damage to the endocardium, possibly mediated via hormonal or humoral agents, may feature in the initial phase of the toxic process. The present observations contribute toward the understanding of the pathophysiology of human anthracycline cardiotoxicity.

Endomyocardial biopsy: a review of the literature

A review of the literature relating to endomyocardial biopsy (EMB) is presented. This is considered important at this time since EMB is being utilized with increasing frequency, particularly for the diagnosis of myocarditis. The development of the technique is briefly outlined. Emphasis is placed on the clinical application of EMB in the various primary cardiomyopathies (dilated, hypertrophic, restrictive, and obliterative), the infiltrative secondary cardiomyopathies (amyloidosis, sarcoidosis, hemochromatosis), myocarditis, as well as such conditions as adriamycin cardiotoxicity, cardiac transplant rejection, and Kawasaki disease. More controversial application of EMB in primary mitral valve prolapse (Barlow's syndrome), idiopathic ventricular arrhythmias, and the elucidation of the enigmatic finding of angina with angiographically normal coronary arteries is detailed. Experience with immunological and biochemical investigation of biopsy material, as well as with virus isolation and drug assays in the myocardium, is alluded to. Complications encountered with this procedure are also discussed, and its future role is contemplated.

Myocardial involvement in acromegaly

We recently encountered a case of an acromegalic patient with congestive heart failure and secondary cardiomyopathy. Cardiac biopsies were available in addition to autopsy material. This enabled us to perform electron microscopical studies which have hitherto not been reported. This may help to clarify the relationship between these two conditions and reveal specific characteristics.

The femoral venous approach to endomyocardial biopsy: comparison with internal jugular and transarterial approaches

Endomyocardial biopsy is often used in the clinical evaluation of cardiac disease. Among 134 consecutive procedures (280 myocardial samples), 3 approaches were compared: right internal jugular (n = 69), femoral arterial (n = 30) and femoral venous (n = 35). The femoral venous approach is a new method with which a preformed guiding sheath is used to allow sampling of the apical right ventricular portion of the ventricular septum. Vascular access and myocardial sampling were successful in all femoral venous and left ventricular (LV) procedures; however, the internal jugular vein could not be located to allow biopsy in 12% of neck approaches (p less than 0.025). One case of pneumothorax occurred after an internal jugular approach. Chest pain occurred after 10% (3 patients) of the LV, 4% (3 patients) of internal jugular and 3% (1 patient) of femoral venous procedures. Hypotension associated with biopsy was noted after 3 internal jugular and 2 LV procedures. Pericardial effusion was observed in 3 patients after an LV procedure (p less than 0.01). In 1 of these patients tamponade developed. The femoral venous approach had the highest overall efficiency (successful biopsy, lack of adverse events, p less than 0.05). This approach may become the procedure of choice for routine endomyocardial biopsy because it allows reliable vascular access and myocardial sampling with a low incidence of adverse reactions.

Differentiating characteristics of myocardial nuclei in cardiomyopathy

Myocardial tissue obtained by endomyocardial biopsy was semiquantitatively evaluated for nuclear and nucleolar characteristics in six groups of patients: patients with normal cardiac function (group 1), doxorubicin-induced cardiomyopathy (group 2), idiopathic cardiomyopathy (group 3), alcoholic cardiomyopathy (group 4), post-viral cardiomyopathy (group 5), and chronic valvular heart disease (group 6). From each patient, ten nuclei containing nucleoli were examined and rated on the basis of the following characteristics: chromatin clumping, number of fibrillar centers per nucleolus, nucleolonemal structure, size of nucleolus, number of nucleoli per nucleus, and stage of nucleolar change. Mean values for the nuclear characteristics in each group were compared with normal values using the unpaired t test. In the doxorubicin treated group there were significantly increased chromatin clumping, decreased fibrillar centers, decreased nucleolonemal structure, and increased numbers of contracted nucleoli (indicating later stage). These changes may be linked to lowered nuclear and nucleolar activity. In the idiopathic and post-viral groups, characteristics were consistent with increased nuclear and nucleolar activity. There were no significant changes from normal in the nucleolar features of either the alcoholic or valvular groups. Further comparisons between groups using one-way analysis of variance and multivariate statistical analysis support the conclusion that there are significant differences in the nuclear and nucleolar characteristics of these groups.

An ultrastructural morphometric study of the papillary muscle of the right ventricle of the cat

The papillary muscle of the cat heart's right ventricle has not been studied previously with quantitative ultrastructural techniques despite its wide use for functional studies. This tissue was perfusion-fixed, processed for electron microscopy, and morphometric techniques were used to assess the ultrastructural characteristics of the papillary muscle as well as the working myocardial cells. The results of this study were that 73.5% of the papillary muscle was composed of muscle cells, 9.7% of blood vessels, and the remainder of interstitial connective tissue. In the muscle cell the volume fraction of mitochondria was 17.3%, that of myofibrils was 49.8%, and that of the nucleus was 2.0%. The mitochondria to myofibrils ratio was 0.36 and the surface to volume ratio was 0.309. In a quantitative ultrastructural comparison of perfusion and immersion fixed tissue it was found that significant differences in the volume density of the blood vessel lumen existed between the two groups. In addition, there were significant differences in the volume fraction of mitochondria and nucleus between perfusion-fixed and immersion-fixed muscle cells. A concurrent significant decrease between the two groups was also found for the ratio of mitochondria to myofibrils. The perfusion-fixed tissue can be considered to provide only normal baseline data for the papillary muscle of the right ventricle. These data are important as they can be used in future structure-function studies on normal and pathological heart tissue.