The role of endomyocardial biopsy in the management of cardiovascular disease: a commentary on joint AHA/ACC/ESC guidelines

Data on the use of endomyocardial biopsy (EMB) in routine cardiological practice are scant, but anecdotal evidence suggests that its frequency varies substantially between centres. The reasons for this variation are unclear, but they almost certainly include differential access to cardiological and pathological expertise, and a lack of consensus on the risk–benefit ratio of EMB in particular clinical situations. A distinguished panel working under the auspices of the American Heart Association (AHA), American College of Cardiology (ACC) and the European Society of Cardiology (ESC) has recently produced a scientific statement on the indications for EMB.1 Refreshingly, the document’s recommendations are based, where possible, on an analysis of clinical scenarios in which EMB might be useful rather than lists of diseases that can theoretically be detected in myocardial tissue samples. The fact that the panel strongly recommended EMB in only two relatively uncommon clinical situations illustrates the urgent need for more data on the clinical utility of EMB in the diagnosis of heart muscle disease. EMB is performed using specifically designed bioptomes and sheaths, via the internal jugular or femoral vein. In some centres, it is routine to perform left ventricular biopsy via the femoral artery, but there are no prospective data on the comparative risks or diagnostic yield of each approach. Similarly, echocardiography is used by some operators to guide placement of the bioptome, but the advantage of this over standard fluoroscopic guidance is unproven. The risks of …