Alternative approaches to right ventricular endomyocardial biopsy

Abstract

Cardiologists are performing endomyocardial biopsy procedures with increasing frequency, particularly in patients who have undergone cardiac transplantation. Because of the necessity for performing multiple biopsies in many of these patients and the subsequent complications that may arise, we have developed a simple and efficient technique for obtaining endomyocardial biopsy samples. As an alternative to retrieving biopsy samples by the conventional right internal jugular or femoral venous approach, we use the right or left internal jugular or subclavian approach. The procedure utilizes a 7 Fr 35 cm sheath and dilator system placed into the right ventricle over a balloon-tipped catheter. After the sheath is positioned via either the internal jugular or subclavian vein, multiple samples can be obtained with standard available bioptomes. The sheath may then be exchanged for a triple-lumen catheter if desired. This approach permits routine changing of the central venous access lines within the sterile confines of the catheterization laboratory, with minimal discomfort to patients. We believe that this method represents an important alternative to conventional biopsy techniques.

Endomyocardial biopsy through the left internal jugular vein in heart transplant recipients: a single center experience

“…9 The LIJV was used thereafter in a limited number of cases in either pediatric or adult recipients. 10,11 In the subsequent years, new bioptomes have been developed which are more flexible and with more extended length, thus easily overcoming possible anatomical barriers, reducing EMB-related complications and increasing the diagnostic efficacy.…”

“…This procedure was successfully performed in a series of patients under fluoroscopic guidance using a rigid biotome apparently without complications; nevertheless, the authors underlined several limitations of this technique related to the presence of acute venous angles between the LIJV and the right atrium and difficulties during manipulation of the bioptome 9 . The LIJV was used thereafter in a limited number of cases in either pediatric or adult recipients 10,11 . In the subsequent years, new bioptomes have been developed which are more flexible and with more extended length, thus easily overcoming possible anatomical barriers, reducing EMB-related complications and increasing the diagnostic efficacy.…”

Novel long-neck sheath for endomyocardial biopsy

“…Long sheaths with a septal plane curve that preferentially orient the sheath tip within the right ventricle adjacent to the septal sampling site are widely employed for biopsy through the femoral approach [5,[10][11][12][13][14]. We and others [5,7,[10][11][12][13][14] have used a long internal jugular sheath with a hockey-stick shape that positions the sheath in the same right ventricle. Unfortunately, the only currently available long internal jugular sheath (Cordis, Miami Lakes, FL) is lacking the important design feature of a septal plane curve.…”

“…However, even in experienced hands, complications occur in 3-6% of procedures [3][4][5][6][7][8][9][10][11][12][13][14]. Although most complications are minor (e.g., inadvertent arterial puncture and transient arrhythmias), biopsy may result in more serious and potentially catastrophic complications including cardiac perforation leading to cardiac tamponade [1][2][3][4][5]9,14] and tricuspid valve damage, occasionally necessitating surgery for severe regurgitation [6][7][8]. Given that the typical cardiac transplantation patient undergoes multiple biopsies over time for rejection surveillance, the impact of these potential complications is cumulative [3,5].…”

“…The concept of a long biopsy guiding sheath that positions the sheath tip adjacent to the target septal site has been established for biopsy along the internal jugular and femoral venous routes [5,7,[10][11][12][13][14][15][16][17][18][19]. Long sheaths with a septal plane curve that preferentially orient the sheath tip within the right ventricle adjacent to the septal sampling site are widely employed for biopsy through the femoral approach [5,[10][11][12][13][14]. We and others [5,7,[10][11][12][13][14] have used a long internal jugular sheath with a hockey-stick shape that positions the sheath in the same right ventricle.…”