Right and Left Ventricular Biopsies
Abstract & Commentary
By Michael H. Crawford, MD
Source: Yilmaz A. et al. Comparative evaluation of left and right ventricular endomyocardial biopsy. Circulation. 2010;122:900-909.
The safety and diagnostic performance of right and left ventricular endomyocardial biopsy in patients with suspected myocarditis or non-ischemic cardiomyopathy is poorly understood, especially with contemporary techniques, such as MRI guidance. Thus, these investigators from two centers in Germany studied 755 patients with suspected myocarditis (n = 481) or non-ischemic cardiomyopathy (n = 274) who underwent LV biopsy (35%), RV biopsy (18%), or both (47%) after exclusion of coronary artery disease by angiography. MRI was performed in 72%.
Results: LV biopsy resulted in four major complications (0.64%), and consisted of two perforations and two strokes. RV biopsy resulted in four perforations (0.82%). Minor complications included transient chest pain, pericardial effusion, and non-sustained VT in both groups. Transient hypotension and temporary heart block was observed in RV-biopsy patients only. The minor complication rate varied from 2%-5% depending on which ventricle biopsy a pericardial effusion was assigned. Diagnostic results were obtained more often with bilateral biopsies (79%) vs. one ventricle (67%, p < 0.001). Using gadolinium enhancement on MRI to direct the biopsy did not enhance the diagnostic yield. Diagnostic histologic findings were absent in 28% of patients. Using biopsy diagnosis as the gold standard, late gadolinium enhancement presence had a sensitivity of 54% and a specificity of 64% for the diagnosis of myocarditis. The authors concluded that both LV and RV biopsy are safe, and combining both enhances the diagnostic yield, but MRI guidance does not.
Commentary
The two interesting aspects of this retrospective review of the experience with endomyocardial biopsies at two German centers are the very low complication rates and the relatively high diagnostic yield. Previous studies of myocardial biopsy for suspected acute myocarditis showed a low yield and no improvement in outcomes. This study used modern diagnostic techniques in addition to histopathology and obtained diagnostically useful information in four out of five patients. Of course, this study was broader than the prior acute myocarditis studies, as they included patients with chronic cardiomyopathies, such as amyloidosis. Also, they used PCR to detect viral genomes. Tissue evidence of myocarditis occurred in 44% of their patients and viral genomes were found in 42%, for a combined diagnostic yield in their series of 61%. The combined yield in those with bilateral biopsies was 71% vs. 51% in those with one ventricle biopsied.
Encouraging data from MRI reports have suggested that MRI with late gadolinium enhancement may be a noninvasive technique for diagnosing myocarditis, or at least a tool for guiding biopsy to higher yield areas. This potential was not realized in this study. MRI exhibited modest sensitivity and specificity for the diagnosis of myocarditis. MRI was performed selectively in about three-quarters of the patients. Late gadolinium enhancement was seen in 53%. It was not feasible to reach every enhanced area with the bioptome, but it could be used to select which ventricle to sample. There was no relation between the location of MRI enhancement and the diagnostic yield of the biopsies. Thus, MRI appears to be of little value in the management of patients with suspected myocarditis.
The low major complication rate of biopsies in this series (< 1% for both ventricles) is encouraging. Of course these are large, experienced centers, so results may vary in different institutions. However, the data suggest that bilateral biopsies should be done, since they significantly increased the diagnostic yield without increasing the major complication rate. Of note, stroke was only observed with LV biopsy. Perforations with hemopericardium were observed with both ventricles.
In experienced hands, bilateral ventricular biopsies are safe and increase the diagnostic yield, especially if modern diagnostic techniques are applied to the samples. What is still unknown is whether this enhanced diagnostic ability alters outcomes in patients with myocarditis.
The safety and diagnostic performance of right and left ventricular endomyocardial biopsy in patients with suspected myocarditis or non-ischemic cardiomyopathy is poorly understood, especially with contemporary techniques, such as MRI guidance.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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