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Echocardiography-Guided Biopsy of Intracardiac Masses
Endomyocardial biopsy (EMB) is a commonly performed procedure for the evaluation of cardiac tissue for transplant monitoring ( 
), myocarditis, drug toxicity, cardiomyopathy, and secondary cardiac involvement by systemic diseases and for diagnosis of cardiac masses. , This chapter discusses only the role of EMB of cardiac masses. Although lesion morphology and location often suggest a diagnosis, histologic evaluation is required before the initiation of potentially toxic chemotherapy or to guide possible surgical approach for resection. There are numerous case reports of EMB being performed for tissue diagnosis of cardiac tumors. The majority of these are malignant or metastatic ( Table 173.1 ).
TABLE 173.1
Malignant Primary or Metastatic Cardiac Tumors Reported in the Literature as Diagnosed by Endomyocardial Biopsy
| Malignant Primary Tumors | Metastatic Tumors |
|---|---|
| Angiosarcoma Fibrosarcoma Granulocytic sarcoma (chloroma) Leiomyosarcoma Lymphoma Malignant fibrous histiocytoma Rhabdomyosarcoma Sarcoma not otherwise specified Synovial sarcoma |
Adenocarcinoma Cervical carcinoma Endometrial carcinoma Lymphoma Melanoma Squamous cell carcinoma |
Video 173.1. Transthoracic echocardiographic guidance of myocardial biopsy of the right ventricular apex in a 24-year-old female cardiac transplant patient. Note that the bioptome “snaps back” from the apex when the myocardium has been biopsied as the bioptome has been withdrawn.
A scientific statement from the American Heart Association (AHA), the American College of Cardiology (ACC), and the European Society of Cardiology (ESC) recommends that “EMB is reasonable in the setting of suspected tumors, with the exception of typical myxomas” (class of recommendation: IIa; level of evidence: C). The AHA/ACC/ESC suggests that EMB for suspected cardiac tumor is appropriate if the following conditions are met: (1) the diagnosis cannot be established by noninvasive modalities (e.g., cardiac magnetic resonance imaging) or less invasive (noncardiac) biopsy; (2) the tissue diagnosis can be expected to influence the course of therapy; (3) the chances of successful biopsy are believed to be reasonably high; and (4) the procedure is performed by an experienced operator. Guidance with transesophageal echocardiography (TEE) is advised when possible.
Technique of Echocardiography Guidance
Lesions have been biopsied in all four cardiac chambers, though the vast majority are performed in right-sided tumors. Although left-sided EMB is possible, it is usually avoided because of the potential for systemic embolism. Biopsy samples can be obtained from the right atrium or right ventricle via the venous route through jugular, subclavian, or femoral veins. From the left atrium or left ventricle, samples can be obtained via transseptal puncture or by direct access through a peripheral artery, usually the femoral or brachial artery. ,
EMB is performed using a bioptome, a biopsy forceps threaded into the heart through a catheter. EMB is typically guided by both fluoroscopy and echocardiography in cardiac catheterization suites. The advantages of fluoroscopy include high temporal resolution and the ability to visualize the tip of the bioptome. However, fluoroscopy guidance also has its limitations. The inability to directly visualize the anatomic or spatial location of the bioptome with respect to the target mass is a major limitation. As a result of this limitation of fluoroscopic guidance, echocardiography has been used as a complementary method of imaging to guide biopsy of intracardiac masses ( Figs. 173.1 and 173.2 ; see 
).
Numerous original articles and case reports have demonstrated the value of 2D transthoracic echocardiography (TTE) to guide EMB. However, TTE may be difficult to perform in patients in the catheterization laboratory who are supine. Further difficulty may be imposed in patients with chest tubes, bandages, obesity, chronic lung disease, mastectomy, and so on. In addition, TTE imaging with the operator’s hands and the ultrasound probe on the chest prevent simultaneous fluoroscopic imaging. Therefore, over the past decade, such biopsies have usually been performed preferentially with the aid of TEE. , ,
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