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Myocardial biopsy: techniques and indications
  1. Rohin Francis,
  2. Clive Lewis
  1. Transplant Unit, Papworth Hospital, Cambridge, UK
  1. Correspondence to Dr Rohin Francis, Department of Cardiology, Papworth Hospital, Papworth Everard, Cambridge, CB23 3RE, UK; rohinfrancis{at}

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Learning objectives

  • Understand how an endomyocardial biopsy is performed and how to maximise diagnostic yield while being aware of the potential complications.

  • Know the indications for endomyocardial biopsy and be familiar with the scenarios when it is unlikely to be useful and may be harmful.

  • Learn the likely future role of endomyocardial biopsy in research and clinical use.


The technique of endomyocardial biopsy (EMB) has been refined over the last 50 years such that it now represents a safe investigation of particular use both when looking for a specific group of diagnoses and the most effective way of detecting rejection in the transplanted heart. Nevertheless, it is not without risk and its implementation varies widely between centres.

A joint scientific statement from the American Heart Association (AHA), the American College of Cardiology (ACC) and the European Society of Cardiology (ESC) published in 2007 remains the core of current guidance, but concedes that large-scale randomised data are scarce and some recommendations are based on accumulated expert opinion.1 However, experts do not always agree, as demonstrated by recommendations in two contemporaneous consensus documents. The 2013 statement from the ESC Working Group on Myocardial and Pericardial Disease recommends EMB for the majority of cases where myocarditis is suspected (level of evidence C),2 while the 2013 ACC/AHA Guideline for the Management of Heart Failure recommends EMB should not be performed in the routine evaluation of patients with heart failure (level of evidence C).3

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The first bioptome designed for transvenous EMB was the Konno-Sakakibara bioptome, developed in 1962.4 Multiple iterations were subsequently devised in many countries,5 including the Stanford Caves-Schultz biopsy forceps produced in 1973.6 The Caves-Schultz bioptome became the prevalent apparatus for percutaneous EMB for the subsequent two decades. Flexible modern single-use bioptomes are similar to the Stanford Caves-Schultz but …

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  • Contributors RF and CL contributed equally to production of the manuscript with no other parties involved.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.