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The role and utility of endomyocardial biopsy (EMB) in the work-up of cardiovascular diseases remains controversial and the practice varies widely in different centers. EMB is a diagnostic modality used to evaluate various cardiac diseases in which non-invasive testing is usually not able to formulate a clinical diagnosis. This activity describes the background, indications, complications, and the technique required to perform an endomyocardial biopsy and highlights the role of the interprofessional team in the care of patients that undergo this procedure. Objectives: Identify the indications and contraindications of endomyocardial biopsy. Describe the equipment and technique in regards to endomyocardial biopsy. Review the potential complications of endomyocardial biopsy. Outline interprofessional team strategies for improving care coordination and communication to enhance the care of patients that undergo endomyocardial biopsy. Access free multiple choice questions on this topic.

The role and utility of endomyocardial biopsy (EMB) in the work-up of cardiovascular diseases remains controversial, and the practice varies widely in different centers. EMB is a diagnostic modality used to evaluate various cardiac diseases in which non-invasive testing is usually not able to formulate a clinical diagnosis. Performing a biopsy is not without complications, and less invasive diagnostic procedures such as cardiac magnetic resonance imaging (MRI) or positron emission tomography (PET) scans outcompete EMB for certain indications. However, there do exist certain conditions and scenarios in which doing an EMB is helpful in establishing the diagnosis when no other diagnostic test yields a substantial diagnosis. As with every diagnostic modality, the EMB procedure has unique characteristics in terms of sensitivity, specificity, and predictive values for different diseases. EMB is a multistep process consisting of deciding about indication, biopsy taking, sample handling, and interpretation. Apart from its clinical use, EMB also serves research purposes.[1]

Complications can be divided into acute and chronic. Dreaded acute complications include pneumothorax, arrhythmias, perforation, pericardial effusion, pericardial tamponade, fistulas, heart block, arterial puncture, pulmonary embolization, nerve block/injury, hematoma, arteriovenous fistula, deep vein thrombosis, and tricuspid valve injury. Tricuspid injury, in particular, can be seen in patients undergoing multiple EMB procedures for transplant surveillance. The majority of regurgitation is tolerable and does not often progress to requiring valve replacement. However, care should be taken to minimize tricuspid valve tissue sampling during biopsies in patients who are known to expect frequent EMB procedures. The overall complication rate and the number of inconclusive samples are rather low, with severe adverse events in less than 1% and minor incidents up to 6% of procedures.[18] Delayed complications include access site bleeding, damage to the tricuspid valve, pericardial tamponade, and deep venous thrombosis. The risks of EMB depend on the clinical state of the patient, the experience of the operator, and the availability of expertise in cardiac pathology. If a patient with an indication for EMB presents at a medical center where expertise in EMB and cardiac pathology is unavailable, transfer of the patient to a medical center with such experience should be seriously considered. Additionally, patients with cardiogenic shock or unstable ventricular arrhythmias may require the care of specialists for the management of heart failure, including ventricular assist device placement and potentially heart transplantation.[19][20]

An interprofessional team should be involved in the care of patients that undergo EMB. This team includes interventional cardiologists, cardiac pathologists, radiologists, and cardiology nurses and technicians. Decision-making regarding EMB should balance the risk of this invasive procedure, its treatment implication, and its diagnostic power compared to other diagnostic methods. EMB is one part of the evaluation of cardiac pathology. As histology illustrates cellular appearance, science evolves with trying to take a more detailed look at the subcellular and molecular levels. The findings of the genetic basis of cardiac diseases led to the common pathway hypothesis of hypertrophic and dilated cardiomyopathy and long QT syndromes.[28][29]