1. DR. SAURAV SINGH

2. Endomyocardial Biopsy(EMB)
 The endomyocardial biopsy remains the gold standarad mode of
investigation for diagnosing many primary and secondary
cardiac conditions.
 EMB a diagnostic interventional procedure after development
and application of cardiac catheterisation and cardiothoracic
surgery.
 In sophisticated centers, evaluation of cardiomyopathic patients
includes a detailed history and physical examination, coronary
angiography and EMB.

3. Importance of EMB to clinicians
 Differentiating between established dilated cardiomyopathy
with no evidence of myocardial inflammation and active
myocarditis.
 Cardiac amyloidosis and myocarditis that can be definitely
diagnosed.
 Used to diagnose specifically various types of myocarditis.

4. INSTRUMENTS
 Newer Flexible Bioptomes used due to less complication rates
Commonly used bioptomes are:
 Single use 50cm Novatome
 Argon endomyocardial biopsy forceps
 Bipal 7 bioptome
 Fluoroscopy is the standard imaging modality used to guide the
biopsy catheter.

8.  The easily assessable anatomy of venous return to the heart with
peripheral access makes the right ventricle an attractive location
for tissue sampling.
 The interventricular septum is the preferred biopsy site due to:
 Its thickness compared with the right ventrical wall
 Its continuity with the left ventricle
 Its location in the natural path of blood flow facilitating vascular
access.
 Myocyte disarray is normally encountered in the region of ventricular
apex and its junction with inter-ventricular septum.
 Free wall perforation and haemopericardium is a major reason for
avoiding the free ventricular wall for biopsy.

11. Left ventricular biopsies(LVB)
 Infrequently done
 Performed by needle biopsy at the time of open heart surgery or
via a trans-septal approach
 Procedure performed percutaneously through the femoral artery,
retrograde through the aortic valve into the left ventricle.
 Disease affecting L.V. walls and L.V. masses are the only
indications for LVB.

13. TISSUE HANDLING
 Proper tissue procurement and handling are essential for
optimal diagnostic evaluation
 Biopsy specimens should be gently extracted from the bioptome
with a needle tip.






10% neutral buffered formalin is needed to diagnose:
Transplant rejection
Unexplained cardiomyopathy
Myocarditis
Infiltrative cardiomyopathies
Cardiac tumors

14.  Zeus fixative or saline (used primarily for immunofluorescence
studies to evaluate antigen-antibody rejection) can be used to
assess allograft rejection.
 Trump’s fixative or 4% glutaraldehyde used for:
 Unexplained cardiomyopathy
 Drug induced cardiotoxicity.
 Specimen in trump’s fixative or 4% glutaraldehyde can be viewed
with Transmission electron microscopy(TEM) in assessing:
 Drug toxicity
 Metabolic/ storage disorders
 Light chain deposition disease

15.  Snap freezing tissue is optimal for preserving tissue for
molecular analysis like PCR and real-time PCR in evaluation of
viral pathogens.
 For routine diagnostic evaluation, overnight processing and
parrafin embedding are sufficient.
 All of the biopsy pieces should be embedded in the same block.

16.  A minimum of 3-6 slides prepared at 4-5micronM thickness
within the paraffin block.
 Multiple paraffin ribbons are placed on each slide.
 Routinely stain with hematoxylin and eosin.
 For emergent cases, a 90min rapid(ultra) processing cycle is
available, and slides can be prepared within 2-3hrs.
 Immunohistochemical, immunofluorescence, and molecular
studies are used for specific studies.

17.  Paraffin section immunohistochemistry is used to evaluate for
infectious endocarditis by CMV, EBV.
 In situ hybridization is helpful to demonstrate the presence of
EBV or other viral genome.
 For diagnostic EMB, a sample should always be set aside for
transmission electron microscopy(TEM)
 The sensitivity of detecting transplant rejection can approach
98% with five adequate biopsy fragments.

18.  The adequacy of tissue fragments is very important for correct
diagnostic accuracy and interpretation.
 The greatest limitation to EMB is Sampling error.

19. Special studies
TEM(transmission electron microscopy) are indicated for
conditions like:
 Cardiomyopathy
 Infiltrative disorders(such as amyloidosis or glycogen storage
disorders)
 Viral myocarditis
 Drugs cardiotoxicity
 Universal fixative is recommended, although any 2%
glutaraldehyde based fixative is suffice.

20. Immunofluorescence
 Allograft rejection
 Cardiomyopathy
Immunohistochemistry




Acute allograft rejection
Amyloidosis
Neoplasm
Cardiomyopathy
Polymerase chain reaction
 Viral genome myocarditis

21. SPECIAL STAINS
 Congo red or sulfated Alcian blue stain for amyloid fibrils.
 Prussian blue stain for Iron deposition.
 Masson’s trichome or Movat pentachrome stains to confirm the
presence of myocyte necrosis or interstitial fibrosis.
 Gomori methanamine silver for Fungi
 Gram stains for Bacteria(endocarditis)

23. ROLE OF ARTIFACTS IN EMB
 Commonest artifact is contaraction bands in myocyte identical
to linear bands on acute ischaemic necrosis and catecholamine
(“pressor”) effect.
 Intussusception or “telescoping” of small arteries confused with
transplantation-related arteriosclerosis and luminal occlusion by
thrombus.
 Accumulation of fresh platelet/ fibrin rich thrombus may be
identified along the endocardial surface of biopsy fragments.

24. (A) Section showing the typical pattern of myofibre disarray that can be seen at
previous biopsy sites.(B) Biopsy artifact showing intussusception of an intramural
vessel, not evidence of occlusion/vasculitis (arrow)
.

25.  Ventricular perforation is identified by the prescence of
mesothelial cells.
 Other commonest is Crush artifact occur while cutting large
specimen.
 Bioptome-induced tissue distortion or Crush artifact can occur.

26. Crush artifact

27. (A) Biopsy artefact showing pinching of the sample at the time of procurement
(arrows). Also note the region of fibrosis,represents the site of an earlier biopsy.
(B) Tissue fragment from transplant showing endocardial fibrosis, secondary to a
healed biopsy site (thick arrow). Also note the region of interstitial fibrosis and
mixed inflammatory infiltrate consistent with a “vasopressor effect” and probably
not the site of a healed episode of rejection.

28. Indication
s of EMB:
Diagnosis and
monitoring of
acute
transplantatio
n rejection
Diagnosis of
tumors
Diagnosis of
storage
disorders
Evaluation of
restrictive
heart disease
such as
amyloidosis
Classification
of myocarditis
Grading of
drugs(anthrac
ycline,
adriamycin)
cardiotoxicity
Evaluation of
recent onset
heart failure
in the absence
of coronary
artery disease

29. CARDIAC ALLOGRAFT REJECTION: TYPIFIED BY LYMPHOCYTIC INFILTRATE WITH
ASSOCIATED DAMAGE TO CARDIAC MYOCYTES

30. .
Graft rejection reaction: (A)Early rejection: Foci of lymphocytic infiltrates. (B)Severe
rejection: Significant lymohoid infiltration and myocyte necrosis

31. Allograft vasculopathy: Graft coronary arteriosclerosis,shows severe diffuse concentric
intimal thickening. The internal lamina(arrow) and media are intact

32. EMB provides useful information in the following
disorders:
Idiopathic hypertrophic cardiomyopathy:
 Shows changes : Myofibrils disarray
Myocyte Hypertrophy
Interstitial fibrosis
Endocardial fibrosis
Fibrous changes in intramyocardiac arteries.
 Commonest finding is basophilic degenerationof myocardium
appears as finely granular basophilic.

33. Hypertrophy myocarditis:disarray, extreme hypertrophy, branching of myocytes as well as
characteristic interstitial fibrosis(collagen is blue in this masson trichome stain).

34. Contd…..
Idiopathic dilated cardiomyopathy:
 Endocardial fibrosis, interstitial fibrosis
 Hypertrophy of myocardial fibers
 Degenerative changes of myocardial fibers
 Leukocytic infiltrates are commonly present
Restrictive myocardiopathy:
 Variable myocyte hypertrophy
 In active stage, heavy component of eosinophils is present
 In inactive stage, various nonspecific changes are seen

35. DCM demostrates variable myocyte hypertrophy and interstitial fibrosis(collagen
is highlighted as blue in Masson trichome stain)

36. Dilated cardiomyocarditis
(A)Shows endocardial fibrosis, myocyte hypertrophy, myocyte nuclei, moderate
interstitial fibrosis.
(B)Shows thickened fibrous endocardium with interstitial fibrosis

37. RESTRICTIVE MYOCARDITIS

38. Classification of Myocarditis :
 Diagnosis of myocarditis requires presence of inflammation
infiltrate and myocyte necrosis or degeneration.
 Etiology can be viral, bacterial, fungal, parasitic, collagen
vascular disease, drug and radiation induced or transplant
rejection
 Infiltrate is of lymphocytic in nature admixed with histiocytes.
 Fibrosis if present should be quantified(mild, moderate, severe)
and qualified(interstitial, endocardial replacement)

39. Contd…
Hypersensitivity myocarditis:
 Eosinophilic infiltrate
 Predominantly perivascular
 Lesser degree of necrotizing changes.
Persistent myocarditis:
 When both the myocyte damage and the inflammation persist
on subsequent biopsies.
Resolving or healing myocarditis:
 When both the myocyte damage and the inflammation are
substantialy reduced, and resolved or healed.

40. HYPERSENSITIVITY MYOCARDITIS: Interstitial infiltrate composed largely eosinophils and
mononuclear inflammatory infiltrate.

41. Contd…
Giant cell myocarditis:
 Characterised by multicentric destruction of the cardiac myocytes by
cytotoxic cells and the multinucleated cells.
 Recently described newer form of myocarditis characterised by T
lymphocytes that express the gamma-delta receptor and runs
a fulminant course.
Lymphocytic myocarditis:
 Active disease: Interstitial inflammatory infiltrate
Focal myocyte necrosis.
Diffuse, mononuclear, lymphocytic infiltrate

42. GIANT CELL MYOCARDITIS: Mononuclear inflammatory infiltrate containing
lymphocytes, macrophages, extensive loss of muscle and multinucleated giant cells.

43. LYMPHOCYTIC MYOCARDITIS: Lymphocyte infiltrate with myocyte injury

44. Contd….
CHAGAS DISEASE:
 Parasitization of myofibrils by trypanosomes
 Inflammatory infiltrate by neutrophils, lymphocytes,
macrophages and occasional eosinophils.
 Myofibrils distended with trypanosomes infiltration.

45. CHAGAS DISEASE: Myofibrils distended with trypanosomes(arrow) is present along with
inflammation and necrosis of individual myofibrils.

49. Contd…
Infiltrative myocardiopathies:
It includes various infiltrating conditions like:
 Amyloidosis
 Hemosiderosis
 Hemochromatosis
 Glycogenosis

50. AMYLOIDOSIS

51. AMYLOIDOSIS

53. AMYLOIDOSIS ON EM

54. Contd…
Drug induced and radiation induced cardiomyopathies:
 Adriamycin shows changes like:
 Vacuolisation of cardiac myocytes is the earliest change
 Appearance of adria cell(characterised by loss of cross striations
and myofilamentous bundles and basophilic staining)
 Inflammation is nil or absent, which differentiates it from other
myocardinal lesions.
 Changes are diffuse, dose dependent and tend to occur in
subendocardial region.

55. Contd…
Cyclophosphamide :
Hemorrhagic necrosis
Intensive capillary thrombosis
Interstitial hemorrhage
Fibrin deposition
Necrosis of myocardial fibers
Radiation induced heart diseases:
Constructive pericarditis
Myocardial fibrosis
Coronary artery lesions

56. DRUG INDUCED MYOCARDITIS

57. The evaluation of an endomyocardial biopsy.
.

58. FINDINGS AND IMPORTANCE
 Surgical pathology report should provide as much as diagnostic
information as possible, it includes:
 Number of pieces of myocardium
 Appearance of myocyte nuclei(hypertrophied, pkynotic,
attenuated, or atrophic)
 Prescence of cytoplasmic pigments
 Pattern of necrosis(focal or diffuse)

59. FINDINGS AND IMPORTANCE
 Composition of interstitium(e.g., cellularity, fibrosis, edema,
amyloid deposits)
 Prescence of endocardial inflammation

60. DIFFERENTIAL DIAGNOSIS
ENDOCARDIUM
FIBROSIS
ULCERATION/
NECROSIS
•
•
•
•
•
•
•
•
Healed myocarditis
Cardiomyopathy
Drug toxicity
Organised thrombus
Healed biopsy site
Healed acute rejection site
Endocardial hyperelastosis
Graft procurement injury
• Healing biopsy site
• Hypereosinophilic syndrome

61. MYOCARDIUM
HYPERTROPHY
Hypertrophic/dilated
cardiomyopathy
Pressure/volume overloaded
ventricle
FIBRE DISARRAY
Hypertrophic cardiomyopathy
Ventricular apex
Healed biopsy sites
Muscle dystrophies
Junction of free wall and
interventricular septum

62. INTERSTITIUM
FIBROSIS
Healed biopsy site
Cardiomyopathy
Drug toxicity
Healed myocarditis
NEUTROPHILS
Fulminant
endocarditis
EOSINOPHILS
Parasitic infection
Hypersensitivity
Hypereosinophilic
syndrome
LYMPHOCYTES
Allograft rejection
Bacterial
endocarditis
Normal allograft
Acute allograft
rejection
Leukaemia
Myocarditis

63. INTRAMURAL VESSELS
Systemic
arterial
hyperten
sion
Hypertrophic
cardiomyopathy
Intramural
vessels
Amyloid
osis
Allograft
vasculopathy

64. COMPLICATIONS
 The current complication rate with the intravascular procedure
•








at specialised centres is less than 1%.
Sampling error( if focal in nature or limited to L.V)
Hemopericardium(most common)
Cardiac perforation(most serious)
Nerve injuries
Hematomas
Cardiac arrhythmias
Tricuspid valve apparatus damage
Pericardial fibrosis/ Thickening
Air embolism and pneumopericardium

65. TAKE HOME MESSAGE
 The endomyocardial biopsy remains the gold standard mode of
investigation, as there is considerable limitation to non-invasive
imaging techniques.
 EMB is used to follow allograft rejection after heart
transplantation.
 EMB is used to diagnose conditions like Cardiomyopathies
Myocarditis
Infiltrative lesions
Arrhythmias
Drug toxicities

66.  EMB is used as a research tool to investigate the natural history
of disease.
 EMB is a safe, simple, and effective interventional procedure
with a very low rate of morbidity and mortality.
 Interpretation of EMB specimens requires knowledge of patients
clinical history.
 It also requires appropriate understanding of cardiovascular
pathophysiolgy.

67.  An approach to endomyocardial biopsy interpretation --




Cunningham et al_ 59 (2) 121 -- Journal of Clinical
Pathology
Rosai and Ackermann’s
Sternberg surgical pathology
Internet
Robbins

68. THANKYOU