Complication rate of transfemoral endomyocardial biopsy with fluoroscopic and two-dimensional echocardiographic guidance: a 10-year experience of 228 consecutive procedures

Impact of shear wave dispersion slope analysis for assessing the severity of myocarditis

This study aimed to elucidate the utility of a novel ultrasound-based technique, shear wave dispersion slope (SWDS) analysis, which estimates tissue viscosity, for evaluating the severity of myocardial inflammation. Experimental autoimmune myocarditis (EAM) at different disease phases [3-week (acute phase): n = 10, 5-week (subacute phase): n = 9, and 7-week (late phase): n = 11] were developed in male Lewis rats. SWDS was measured in the right and the left ventricular free walls (RVFW and LVFW) under a retrograde perfusion condition. Histological myocardial inflammation was evaluated by CD68 staining. The accumulation of CD68-positive cells was severe in the myocardium of the EAM 3-week group. The median (interquartile range) SWDS of RVFW was significantly higher in the EAM 3-week group [9.9 (6.5-11.0) m/s/kHz] than in the control group [5.4 (4.5-6.8) m/s/kHz] (P = 0.034). The median SWDS of LVFW was also significantly higher in the EAM 3-week group [8.1 (6.4-11.0) m/s/kHz] than in the control group [4.4 (4.2-4.8) m/s/kHz] (P = 0.003). SWDS and the percentage of CD68-positive area showed a significant correlation in RVFW (R2 = 0.64, P < 0.001) and LVFW (R2 = 0.73, P < 0.001). This study showed that SWDS was elevated in ventricular walls with acute inflammation and also significantly correlated with the degree of myocardial inflammation. These results suggest the potential of SWDS in estimating the histological severity of acute myocarditis.

Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant (HTx) rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples have significantly improved diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (i) an overview of the practical approach to EMB, (ii) an update on indications for EMB, (iii) a revised plan for HTx rejection surveillance, (iv) the impact of multimodality imaging on EMB, and (v) the current clinical practice in the worldwide use of EMB.

Heart Failure Association, Heart Failure Society of America, and Japanese Heart Failure Society Position Statement on Endomyocardial Biopsy

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumors. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples has significantly improved the diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (1) an overview of the practical approach to EMB, (2) an update on indications for EMB, (3) a revised plan for heart transplant rejection surveillance, (4) the impact of multimodality imaging on EMB, and (5) the current clinical practice in the worldwide use of EMB.

Early Disseminated Lyme Carditis Inducing High-Degree Atrioventricular Block

Lyme disease is the most common tick-borne illness in the United States due to Borrelia burgdorferi infection. This case demonstrates a 20-year-old male patient presenting with complaints of annular skin rash, malaise, fever, and lightheadedness after significant outdoor exposure. Physical exam revealed multiple large targetoid lesions on the back and extremities. The rash had raised borders and centralized clearing consistent with erythema migrans chronicum. Electrocardiogram (ECG) revealed a high-degree atrioventricular (AV) block. The patient was started on intravenous ceftriaxone due to clinical suspicion for Lyme carditis. ELISA and Western blot tests were reactive for Lyme IgM and IgG, confirming the diagnosis. The AV block resolved by hospital day four and the patient was discharged with outpatient follow-up. Early identification of disease allowed for effective treatment with no adverse outcomes or sequelae.

National Trends and Procedural Complications from Endomyocardial Biopsy: Results from the National Inpatient Sample, 2007–2014

Aim: The aim of this study is to report recent trends in the performance of endomyocardial biopsy (EMB) and its in-hospital complications (and their predictors) in the United States (US). Method: We analyzed Nationwide Inpatient Sample (NIS) database from years 2007 through 2014 to identify patients who underwent EMB. Once identified, the patients were subdivided into those with no history of heart transplant (HT) (cohort 1) and those with history of HT (cohort 2). We then studied the major complication of pericardial effusion, hemopericardium or/and cardiac tamponade that required a pericardiocentesis or a pericardial window (CTRPD) following the EMB procedure. Results: We observed a steady increase in the in-patient EMB procedures, with more EMB procedures being performed in males and in Caucasians. In cohort 1, the CTRPD was higher (0.70%) as compared to cohort 2 (0.19; p = 0.01). CTRPD in women was higher compared to men (0.94 vs. 0.53% p = 0.022). Most of the EMB procedures are performed in teaching hospitals. The CTRPD rate was significantly higher in the nonteaching hospitals when compared to teaching hospitals in both cohort 1 and cohort 2 (3.4 vs. 0.53% and 1 vs.0.18%, respectively; p = 0.01 and < 0.001, respectively). The overall mortality in cohort 1 was 4.3% as compared to 2.5% in cohort 2; p = 0.01. In cohort 1, the mortality was significantly higher in the group that had EMB-related complications versus the group without the complications (20 vs. 2.5%; p < 0.001). Conclusion: There has been an increase in the number of EMB procedures in the US in recent years. Though the overall risk of CTRPD is very low, the risk is significantly higher in cohort 1, women, and in nonteaching hospitals. The study results provide data benchmarks for assessing EMB outcomes in the US.

Comparison of Utilization Trends, Indications, and Complications of Endomyocardial Biopsy in Native Versus Donor Hearts (from the Nationwide Inpatient Sample 2002 to 2014)

Native heart endomyocardial biopsy (NH-EMB) is an infrequently performed procedure. The objective of this study is to describe utilization trends, indications, and complications associated with NH-EMB in the United States and compare them with transplanted heart endomyocardial biopsy (TH-EMB). Using the Healthcare Cost and Utilization Project National Inpatient Sample database, we identified 71,105 adult patients undergoing EMB in the inpatient setting in participating hospitals from 2002 to 2014. A total of 20,770 (29%) were performed on NHs (mean age 52.2 ± 15.3, 61% men). Approximately half of patients were white and mean Charlson co-morbidity index was 1.97 ± 1.6. Common indications for NH-EMB included a suspected primary cardiomyopathy (disorder confined to the myocardium), heart failure without cardiogenic shock, and acute myocarditis. Less common indications included heart failure with cardiogenic shock, unexplained heart failure with ventricular tachycardia or high-degree atrioventricular block, and cardiac neoplasms. Complications included pericardial effusion (3.8%), third-degree atrioventricular block (2.7%), vascular complications (1.9%), and deep venous thrombosis (3.5%), in others. Predictors of complications included presence of a cardiac malignant neoplasm, use of hemodynamic support, heart failure with ventricular tachyarrhythmias, and female gender. Compared with NH-EMB, TH-EMB was associated with lower rates of pericardial effusion, third-degree atrioventricular block, ventricular tachyarrhythmias requiring cardioversion, and higher rates of deep venous thrombosis, infections, and pneumothorax. NH-EMB utilization is low in the United States and constitutes less than 1/3 of all EMBs performed.

Endomyocardial biopsy via the femoral access - still safe and valuable diagnostic tool

BACKGROUND

The endomyocardial biopsy has proven to be an integral diagnostic tool for surveillance of cardiac allograft rejection and identification of myocardial diseases. Nevertheless, this invasive procedure is not risk-free. This study focuses on the risk of complications and diagnostic performance of right ventricular endomyocardial biopsy (EMB).

METHODS

In this single-center retrospective study, we analyzed 315 EMB procedures performed between July 2008 and May 2015 in 73 patients. All EMBs were made via the right femoral vein approach under fluoroscopic control to evaluate suspected myocarditis, unclear heart failure, unexplained cardiomyopathy, assumed infiltrative and storage disease or as a part of routine allograft rejection monitoring and clinically suspected rejection diagnosis after heart transplantation (HTx). Obtained specimens were diagnosed histopathologically by one experienced pathologist. All patients underwent a 12-lead electrocardiogram (ECG), ECG monitoring, transthoracic echocardiography before and after EMB to obtain a detailed assessment of the incidence of heart rhythm disorders, pericardial effusions or worsening valve insufficiency. Complications resulting from the procedure were classified as major or minor according to the risk of death.

RESULTS

Among all the 315 biopsies, 86.67% were performed in 32 patients after HTx, 3.81% in patients with myocarditis, 2.54% in patients with dilated cardiomyopathy and 1.9% in patients with amyloidosis. The overall complications rate was 1.9% (6 of 315 procedures). Major complications included perforation with pericardial tamponade requiring surgical intervention (0.64%, 2 of 315 procedures). Minor complications included: pericardial effusion (0.32%, 1 of 315 procedures), local hematoma (0.64%, 2 of 315 procedures) and right coronary artery-right ventricle fistula in HTx recipient (0.32%, 1 of 315 procedures).

CONCLUSIONS

EMB is a safe procedure with low risk of serious complications and high effectiveness for the evaluation of unexplained left ventricle dysfunction and monitoring allograft rejection after HTx.

Diagnostic performance of cardiac magnetic resonance for the detection of acute cardiac allograft rejection: a systematic review and meta-analysis

BACKGROUND

Several studies have addressed the diagnostic accuracy of cardiac magnetic resonance (CMR) to assess acute cardiac allograft rejection (ACAR) compared with endomyocardial biopsy (EMB). But the methodological heterogeneity limited the clinical application of CMR. Accordingly, we have sought a comprehensive, systematic literature review and meta-analysis for the purpose.

METHODS

Studies prior to September 1, 2014 identified by Medline/PubMed, EMBASE and Cochrance search and citation tracking were examined by two independent reviewers. A study was included if a CMR was used as a diagnostic test for the detection of ACAR.

RESULTS

Of the seven articles met the inclusion criteria. Only four studies using T2 relaxation time as a CMR parameter could be pooled results, because the number of studies using other parameters was less than three. By using DerSimonian-Laird random effects model, meta-analysis demonstrated a pooled sensitivity of 90% [95% confidence interval (CI), 79% to 97%], a pooled specificity of 83% (95% CI, 78% to 88%), and a pooled diagnostic odds ratio (DOR) of 61.66 (95% CI, 18.09 to 210.10).

CONCLUSIONS

CMR seems to have a high sensitivity and moderate specificity in the diagnosis of ACAR. However, as a result of CMR for diagnostic ACAR should be comprehensively considered by physicians and imaging experts in the context of clinical presentations and imaging feature. Further investigations are still required to test different parameters and study condition.

Transthyretin V122I amyloidosis with clinical and histological evidence of amyloid neuropathy and myopathy

Hereditary transthyretin amyloidosis (ATTR) is a genetically and clinically heterogeneous disease manifesting with predominant peripheral and autonomic neuropathy; cardiomyopathy, or both. ATTR V122I is the most common variant associated with non-neuropathic familial amyloid cardiomyopathy. We present an unusual case of V122I amyloidosis with features of amyloid neuropathy and myopathy, supported by histological confirmation in both sites and diffuse tracer uptake on (99m)Tc-3,3-Diphosphono-1,2-Propanodicarboxylic acid (DPD) scintigraphy throughout skeletal and cardiac muscle. A 64 year old Jamaican man presented with cardiac failure. Cardiac MR revealed infiltrative cardiomyopathy; abdominal fat aspirate confirmed the presence of amyloid, and he was homozygous for the V122I variant of transthyretin. He also described general weakness and EMG demonstrated myopathic features. Sural nerve and vastus lateralis biopsy showed TTR amyloid. The patient is being treated with diflunisal, an oral TTR stabilising agent. Symptomatic myopathy and neuropathy with confirmation of tissue amyloid deposition has not previously been described. Extracardiac amyloidosis has implications for diagnosis and treatment.

[Capabilities of 99mTc-pyrphotech single-photon emission computed tomography in combination with myocardial perfusion scintigraphy in the evaluation of inflammatory changes in the heart of patients with persistent atrial fibrillation]

AIM

To estimate the capabilities of 99mTc-pyrphotech single-photon emission computed tomography (SPECT) in the diagnosis of myocardial inflammatory changes in patients with persistent atrial fibrillation (AF).

SUBJECTS AND METHODS

Nineteen patients (11 males and 8 females, mean age 47.46 ± 9.92 years) with persistent idiopathic AF underwent preoperative complete clinical and instrumental examination. 99mTc-pyrphotech SPECT was performed to identify foci of myocardial inflammatory changes. After completing 99mTC-pyrphotech scanning, resting myocardial perfusion scintigraphy with 99mTC-methoxyisobutylisonitrile (99mTc-MIBI) was performed in accordance with the standard protocol. The scintigrams obtained in both studies were then combined using the applied programs Jet Stream Workspace Release 2.5 (Philips) and the application Fusion. During invasive intervention, endomyocardial samples were intraoperatively taken from all the patients for histological and immunohistochemical examinations.

RESULTS

Abnormal 99mTc-pyrphotech myocardial accumulation was found in 7 (36.8%) of the examinees, multiple foci in 3 cases and single foci in 4. Analysis of perfusion scintigrams indicated that the mean abnormal accumulation of 99mTc-MIBI in the left ventricle was 3.75 ± 0.88% (maximum 9%). Histological examination of endomyocardial samples from 19 patients with persistent AF verified myocarditis in 4 (21%) patients and myocardial sclerosis concurrent with other abnormalities in 15 (78.9%) patients.

CONCLUSION

Latent lymphocytic or polymorphic cellular myocarditis of viral etiology is a cause of idiopathic AF in 20% of the cases. 99mTc-pyrphotech scintigraphy may be one of the primary noninvasive diagnostic techniques for the detection of myocardial inflammation in this form of arrhythmia.