Left Ventricular Biopsy in the Diagnosis of Myocardial Diseases
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Myocardial biopsies have been performed as early as 1956, initially via transthoracic needle, and in 1962 for the first time in a transvenous approach. A consensus statement of the American Heart Association, American College of Cardiology, and European Society of Cardiology endorsed the acquisition of biopsies in several clinical scenarios in which biopsy-guided diagnostics can identify a treatable specific cause. Hence, a Class I indication (Evidence Level B) was ascribed to cases with new onset of unexplained heart failure with hemodynamic compromise, heart failure with ventricular arrhythmia or conduction disease, and heart failure unresponsive to conventional treatment, respectively.1 Eleven other clinical scenarios including the diagnostic workup of “stable” cardiomyopathies have been assigned Class IIa/IIb recommendations. It is important to note that this scientific statement has not been updated since 2007. Thus, the potential contribution of advanced molecular diagnostics of tissue samples in a precision medicine approach has not yet been considered.
Indications, Type of Biopsy, and Access Route
Traditionally, endomyocardial biopsies (EMBs) have been obtained from the right ventricle (RV) via central venous access. While seemingly easier, this strategy appears counterintuitive because the clinical consequences of many relevant pathologies affect predominantly the left ventricle (LV), for example, in most cases of cardiomyopathy or myocarditis. For instance, in sarcoidosis, granulomas are less frequently located in the RV, which lowers the sensitivity of diagnosing this treatable condition. Indeed, …