Cardiovascular Pathology 21 (2012) 245–274 Original Article 2011 Consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology ⁎ ⁎ Ornella Leone a, , John P. Veinot b, , Annalisa Angelini c, Ulrik T. Baandrup d, Cristina Basso c, Gerald Berry e, Patrick Bruneval f, Margaret Burke g, Jagdish Butany h, Fiorella Calabrese c, Giulia d'Amati i, William D. Edwards j, John T. Fallon k, Michael C. Fishbein l, Patrick J. Gallagher m, Marc K. Halushka n, Bruce McManus o, Angela Pucci p, E. René Rodriguez q, Jeffrey E. Saffitz r, Mary N. Sheppard g, Charles Steenbergen n, James R. Stone r, Carmela Tan q, Gaetano Thiene c, Allard C. van der Wal s, Gayle L. Winters r aBologna, Italy bOttawa, Ontario, Canada cPadua, Italy dHjoerring, Denmark eStanford, CA, USA fParis, France gLondon, UK hToronto, Ontario, Canada iRome, Italy jRochester, MN, USA kNew York, NY, USA lLos Angeles, CA, USA mSouthampton, UK nBaltimore, MD, USA oVancouver, BC, Canada pPisa, Italy qCleveland, OH, USA rBoston, MA, USA sAmsterdam, The Netherlands Received 3 August 2011; received in revised form 28 September 2011; accepted 7 October 2011 Abstract The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims: • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization ⁎ Corresponding authors. O. Leone is to be contacted at U.O. di Anatomia ed Istologia Patologica, pad. 18, Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Via Massarenti, 9, 40138 Bologna. Tel.: +39 051 6364511; fax: +39 051 6364571. J.P. Veinot, Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada K1H 8L6. Tel.: +1 613 737 8291; fax: +1 613 737 8712. E-mail addresses: [email protected] (O. Leone), [email protected] (J.P. Veinot). 1054-8807/11/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.carpath.2011.10.001 246 O. Leone et al. / Cardiovascular Pathology 21 (2012) 245–274 • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers. © 2012 Elsevier Inc. All rights reserved. Keywords: Biopsy; Consensus; Heart; Molecular biology; Myocardium 1. Introduction standardized diagnostic histopathologic criteria to minimize EMB reporting variability [2,46,47]. Endomyocardial biopsy (EMB) is a commonly performed As EMB is usually a nontargeted biopsy procedure and procedure for the evaluation of cardiac tissue for transplant false-negative results are possible, especially when used monitoring [1,2], myocarditis [3–5], drug toxicity, cardio- for multifocal or microfocal or localized diseases [36,48,49], myopathy (CMP) [3,6–8], arrhythmia [9–14], and secondary some general rules can optimize diagnostic accuracy: cardiac involvement by systemic diseases [8], and for the diagnosis of cardiac masses [15–21]. Others have high- ■ EMB timing appropriate to specific disease [24,50,51], lighted EMB utility from prognostic–therapeutic [22–24] ■ adequate bioptic sampling with multiple specimens and pathogenetic view points [25]. from different sites (guided by imaging techniques Pathologists should assume responsibility for providing when indicated) [26,36,52,53]. input concerning the utility of the cardiac biopsy for specific diseases and provide guidance for tissue triage and standards 3. Techniques and risks of morphologic evaluation [26]. This implies considering both the recent developments in myocardial and viral EMB involves percutaneous insertion into the heart of a molecular biology and advances in imaging, electrophysio- fluoroscopically or ultrasound-directed sheath, which allows logy, and genetics, and understanding how these techniques safe and rapid insertion of the bioptome and facilitates can complement traditional histopathology. The invaluable obtaining multiple specimens. expertise of the pathologist in morphological tissue assess- Bioptic samples can be taken from the right ventricle, via ment may be essential in outlining appropriate diagnostic the venous route through jugular, subclavian, or femoral strategies in collaboration with clinicians, imagers, molec- veins, or from the left ventricle with transseptal puncture or ular biologists, and geneticists. by direct access through a peripheral artery, usually the Referral of the tissue to expert pathologists and molecular femoral or brachial artery [5,54,55]. For better anatomic biologists is warranted in many cases, given the complexity definition of the specimen site, noninvasive techniques of of the diagnostic tests. cardiac imaging may usefully be associated, such as Moreover, pathologists should endeavor to use uniform gadolinium magnetic resonance imaging (MRI) in targeting reference criteria and language in their reports, including: bioptic specimens in suspected myocarditis [56] and electroanatomic mapping guided techniques in arrhythmo- • degrees of diagnostic certainty: for example, certain– genic right ventricular cardiomyopathy (ARVC) [10,11,57]. definite, probable, possible, nonspecific; Echocardiography allows accurate intracardiac insertion of • biopsy sample adequacy evaluation: for example, the bioptome without the use of ionizing radiation [58,59] optimal, suboptimal. and may be useful in biopsy of cardiac masses. The principal complications of EMB include hematoma, These guidelines should be viewed as recommendations arteriovenous fistula, vasovagal reaction, pneumothorax, and not as mandatory requirements. They represent an overall consensus of the committee members and the opinions expressed are not necessarily those of all members Table 1 of the Association for European Cardiovascular Pathology Technical procedures for light microscopy examination and/or the Society for Cardiovascular Pathology. Routine procedure Fixation in buffered formalin for 15–30 min Processing in automatic processor overnight Rapid procedure for Microwave fixation 2. Recommendations, limits, and precautions transplant and urgent Processing in microwave or vacuum-prepared diagnostic biopsies automatic processor (maximum 30–40 min) The modern view of diagnostic EMB requires the Cutting (routine Serial and numbered sections of paraffin- and rapid) embedded biopsies using at least two thirds of pathologist to have specific professional training [27], use the samples accurate specimen processing [28], and support when Half the cut sections are stained with warranted the traditional histological examination with hematoxylin–eosin; the others are mounted on histochemical, immunohistochemical (IHC), molecular, or sialinized slides (or on slides with polylysine or ultrastructural tests (Tables 1 and 2) [24,29–45] and apply electrostatic charge) for possible further stains. O. Leone et al. / Cardiovascular Pathology 21 (2012) 245–274 247 Table 2 Stains on paraffin-embedded and frozen tissue Stains on formalin-fixed and paraffin-embedded sections Histomorphological and ▪ Masson or Mallory trichrome, Movat pentachrome, Weigert–Van Gieson for collagen and elastic fibers histochemical stains ▪ PAS with and without diastase for glycogen storage (better on frozen sections) ▪ Congo red, sulfate alcian blue, or S/T thioflavin for amyloid ▪ Perls' iron IHC stains ▪ CD45, CD20, CD3, CD4, CD8, CD68/PGM1, HLA-DR. HLA-ABC for inflammatory and cellular infiltrate assessment ▪ Transthyretin, kappa and lambda chains, apolipoprotein, amyloid A component for amyloid typing ▪ Appropriate antibodies for neoplasm characterization ▪ Dystrophin, lamin A/C a, desmin, a plakoglobin, a N-cadherin a for some genetic CMPs Stains on frozen sections Histomorphological and Sudan black, oil red 0, PAS with and without diastase histochemical stains Histoenzymatic stains SDH and COX Immunofluorescence stains Many immunostains listed above, including amyloid subtypes and desmosomal proteins, may be performed on frozen tissue. Frozen tissue may be better than immunohistochemistry for dystrophin (−COOH and NH2 ends, intermediate domain) and HLA-ABC. PAS = periodic acid-Schiff; SHD = succiante dehydrogenase; COX = cytochrome oxidase. a In the course of validation for diagnostic use. arrhythmia, heart block, infection, tricuspid valve damage, ■ brady- or major ventricular tachyarrhythmias to iden- pulmonary embolism or systemic embolism during left tify or exclude possible myocardial causes of arrhyth- ventricular biopsy, and cardiac chamber perforation with mias (e.g., myocarditis, ARVC, sarcoidosis, etc.), possible hemopericardium and cardiac tamponade [60,61]. ■ chronic heart failure to evaluate myocardial diseases In skilled hands, EMB is a safe procedure [55]. The with dilated–hypokinetic or hypertrophic–restrictive overall complication rate is low (1%–2%) [5]. In particular, phenotype, the risk of cardiac perforation was estimated at 0.4% in the ■ acute exacerbation of chronic CMP, largest case records in the world published in 1980 [62] and ■ investigation of cardiac masses, and at 0.12% in more recent data regarding a large number of ■ assessment of cardiac transplant biopsy specimens. patients (3048 cases) [63]. 5. Pathological