Safety and diagnostic performance of endomyocardial biopsy: a single-centre experience
M Grine, G Abel, T Camacho, F Saraiva, J Borges-Rosa, M Oliveira-Santos, V Matos, M Costa, L GoncalvesAbstract
Background
Endomyocardial biopsy (EMB) continues to serve as the gold standard for the diagnosis of myocardial disease and for surveillance of cardiac allograft rejection. However, its clinical utility must be balanced against the inherent procedural risks. Contemporary large-scale, real-world data remain limited. This study aimed to assess the diagnostic performance, technical success, and safety of EMB.
Methods
We conducted a retrospective analysis of all EMB procedures performed between November 2003 and August 2025. Patient demographics, clinical indications, procedural characteristics, and histopathological findings were obtained from electronic medical records. Procedures lacking sufficient documentation were excluded. Technical success was defined as completion of the biopsy via the intended vascular access with an adequate number and quality of tissue samples. Diagnostic yield was defined as the proportion of procedures providing clinically actionable pathological information.
Results
A total of 3,303 EMB procedures, yielding 6,544 tissue samples (mean of 2 fragments per procedure), were included. The vast majority of biopsies were performed for routine cardiac transplant rejection surveillance (n=3252; 98%), with transfemoral access used in 97% of cases. Procedural failure was uncommon (n=32; 0.97%) and was most frequently attributed to sampling of fibrotic tissue, likely related to prior biopsy scarring; valvular tissue, adipose tissue, and thrombus were less common causes. Among biopsies performed for rejection surveillance, 99% were diagnostic, with rejection grades distributed as follows: 90% grade 0R, 8% grade 1R, 2% grade 2R, and 0.47% grade 3R according to ISHLT 2005 criteria. Of the 50 biopsies performed for non-transplant indications, 36 (72%) established an etiologic diagnosis. Complications were rare (n=29; 0.88%) and predominantly minor, including vasovagal reactions (n=4), access-site hematomas (n=2), and one femoral pseudoaneurysm treated successfully with thrombin injection. Arrhythmic events included atrial fibrillation (n=1), atrial flutter requiring cardioversion (n=1), transient atrioventricular conduction abnormalities (n=3), and one episode of ventricular tachycardia managed promptly with propranolol. Fourteen small coronary artery fistulas were identified, none requiring intervention. Two cases of myocardial perforation resulting in tamponade required pericardial drainage, with full recovery in both patients. No additional major complications were observed.
Conclusions
In this large single-centre experience, EMB was associated with a high technical success rate and a low incidence of complications. These findings reinforce the role of EMB as a safe and clinically valuable procedure, particularly for the postoperative management of heart transplant recipients. Consistent with contemporary practice, the overall rejection burden was low, with most biopsies demonstrating grade 0R rejection.