Relative efficiency and risk of endomyocardial biopsy: Comparisons in heart transplant and nontransplant patients

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Abstract
Right ventricular endomyocardial biopsy remains the gold standard for the diagnosis of acute rejection of the cardiac allograft. Among 704 consecutive procedures performed in 39 transplant recipients (2,842 myocardial samples), endomyocardial biopsy by either the right internal jugular (n = 661) or the femoral venous (n = 43) approach was compared with 243 consecutive procedures performed in nontransplant patients (n = 149 and n = 94, internal jugular and femoral approach, respectively). The internal jugular vein could not be located In only 0.61% (4/661) of heart transplant versus 5% (7/149) of nontransplant procedures (P < 0.001). Vascular access plus sufficient myocardial sampling was obtained in all but 0.61% (4/661) internal jugular procedures performed in heart transplant patients and in all but 7% (11/149) of those performed in nontransplant patients (P < 0.0001). (Vascular access was achieved in all femoral venous procedures performed in both transplant and nontransplant patients; sampling was successful after vascular access in all heart transplant recipients and all but two [2.1%] nontransplant procedures.) Cardiac complications occurred in nontransplant patients after one internal jugular procedure (cardiac perforation with tamponade) and after one femoral venous procedure (pericardial effusion). No cardiac complications occurred in transplant recipients, but 2 other complications were observed: One local abscess and one superior vena caval perforation with hemothorax associated with hypotension, both after an internal jugular approach. The overall efficiency (no safety problem; vascular access and adequate sample) was higher among transplant than nontransplant procedures (99% vs 93%, respectively, P < 0.0001). These observations continue to support routine application of endomyocardial biopsy for monitoring rejection in cardiac transplant patients. Safety and effectiveness of a single transvenous biopsy procedure in nontransplant patients, although still high, may not be equal to that predicted by the experience in transplant patients. These observations plus the more controversial nature of biopsy indications for nontransplant applications suggest greater caution in its use in nontransplant patients.