Heart Biopsy (Cardiac Biopsy)

A heart biopsy is a medical test that removes tiny samples of heart muscle tissue for examination under a microscope. This test plays a vital role in monitoring heart transplant patients and diagnosing various heart conditions that affect the heart muscle.

Table of contents

• What is a heart biopsy?
• Other names for this procedure
• Who needs a heart biopsy?
• Who performs the procedure?
• How to prepare for a heart biopsy
• What happens during the procedure
• Recovery and aftercare
• Risks and complications

What is a heart biopsy?

A heart biopsy is a diagnostic procedure that involves removing a small amount of tissue from the inner lining of the heart muscle. A specialist in a laboratory examines the tissue under a microscope to look for changes in cells that indicate damage or abnormalities^[1].

The procedure is done through cardiac catheterization, which means a thin, flexible tube is threaded through blood vessels to reach the heart^[1]. During the procedure, a doctor uses a special device called a bioptome with small jaws on the tip to remove small pieces of tissue from the heart muscle^[2]. The tissue samples taken are very small, similar to the size of a pinhead, and should not affect how the heart works^[5].

Cardiac biopsy, Endomyocardial biopsy, Myocardial biopsy

Other names for this procedure

Healthcare providers use several different terms to refer to this test, including cardiac biopsy, endomyocardial biopsy, and myocardial biopsy^[1].

Who needs a heart biopsy?

The most common reason for a heart biopsy is to check for signs of organ rejection in people who have received a heart transplant. A heart biopsy can often detect organ rejection before symptoms appear and can help identify the cause of rejection^[1].

After a heart transplant, patients may need multiple biopsies to monitor their new heart. Immediately after the transplant, the test may be done weekly. Then it may be performed every six weeks to three months for at least a year^[1]. For heart transplant patients, routine biopsies are typically done approximately every week for the first four weeks after surgery, then with less frequency depending on the patient’s condition. After six months, most patients can have routine biopsies every three months^[3]. The biopsy is currently the only reliable means of diagnosing heart rejection and is performed at regular intervals to assess the adequacy of anti-rejection therapy^[3].

Doctors may also perform heart biopsies to diagnose several other conditions affecting the heart muscle^[1]:

• ATTR (transthyretin) amyloidosis
• Cardiomyopathy (a weakened heart muscle), including hypertrophic cardiomyopathy
• Cardiotoxicity from chemotherapy
• Heart cancer
• Heart failure
• Heart infections like myocarditis (inflammation of the heart muscle)
• Sarcoidosis (a condition causing tissue inflammation)

People with certain health conditions, such as heart valve disease, may have an increased risk of complications following a heart biopsy. It is important to talk with a healthcare provider to determine if this procedure is appropriate^[1].

Who performs the procedure?

A cardiologist, a medical doctor with advanced training in diagnosing and treating heart problems, performs heart biopsies. The doctor has specialized expertise in using catheter-based approaches to examine and treat the heart^[1].

How to prepare for a heart biopsy

Before the procedure, patients should provide their healthcare provider with a current list of all medications and supplements they take. Some medicines, such as blood thinners, may need to be stopped before the test^[1]. Patients are generally told not to eat or drink anything for six to eight hours before the test^[2].

The biopsy takes place in a hospital as an outpatient procedure. Typically, patients come to the hospital on the day of the test, although in some cases they may need to be admitted the night before^[6]. Patients will wear a hospital gown during the procedure and should leave valuables such as jewelry at home^[6].

If coming in for an outpatient biopsy, some centers recommend not taking diuretics the evening before or morning of the biopsy, having a salty meal the night before, and avoiding lifting heavy objects for 24 hours following the biopsy^[3].

Since a sedative will be given during the procedure, patients should arrange for someone to drive them home afterward^[1].

What happens during the procedure

A heart biopsy is an outpatient procedure that typically takes about 30 minutes to one hour^[1][3]. Before the procedure begins, a nurse will start an intravenous line in the arm so that medications and fluids can be given^[6].

Patients receive a mild sedative to help them relax, but they remain awake and conscious during the procedure^[1][2]. A local anesthetic is used to numb the area where the catheter will be inserted^[1].

The doctor typically makes a small incision in the right side of the neck, although sometimes the catheter is placed through a blood vessel in the groin or arm if the neck veins are not accessible^[2][3]. A short, hollow tube called a sheath is inserted through the incision into a blood vessel. The bioptome, a longer and thinner catheter with a miniature grasping device on the end, is then threaded through the sheath^[8].

The doctor uses special imaging to guide the catheter to the correct position in the heart. This may be fluoroscopy (continuous X-ray images), echocardiography (ultrasound), or other imaging techniques^[1][2]. The imaging helps guide the bioptome through the blood vessel and into the right ventricular chamber of the heart^[3].

Once the catheter is in position, the jaws of the bioptome are opened and closed to snip off and retrieve tiny pieces of tissue from the heart muscle^[1][3]. Patients may feel some pressure and slight discomfort during the procedure but should not experience pain^[1].

After collecting the tissue samples, the doctor withdraws the bioptome and removes the catheter. A pressure bandage is applied at the insertion site to stop any bleeding^[1]. The tissue samples are sent to a laboratory for examination, and results are usually available within 24 to 48 hours^[3].

Recovery and aftercare

After the procedure, healthcare providers will monitor the patient’s recovery for a few hours to check for signs of problems^[1]. During this time, chest X-rays are taken to look for signs of potential complications such as a collapsed lung or bleeding between the chest wall and lungs^[1].

Most patients can go home the same day, but someone should drive them home and stay with them during recovery^[1]. Following the biopsy, patients are typically asked to keep their head upright to avoid increased pressure in the blood vessel, which could result in bleeding at the biopsy site^[3].

Patients may have swelling, bruising, or a small lump around the site where the catheter was inserted^[7]. The bandage over the insertion spot should be kept in place for one to two days and will usually fall off during this time^[7]. Ice or a cold pack can be applied to the area for 10 to 20 minutes at a time to help with soreness or swelling^[7].

Patients should not do strenuous exercise or lift, pull, or push anything heavy until their doctor says it is safe to do so, which may be for a couple of days^[7]. Light activities around the house, such as cooking, are generally acceptable^[7]. If the catheter was placed in the groin, patients should try not to walk up stairs for the first couple of days^[7].

Patients may shower 24 to 48 hours after the procedure if their doctor approves, but should not take a bath for one week or until their doctor says it is okay^[7]. A small amount of blood on the bandage (up to the size of a quarter) can be normal. If bleeding occurs, patients should lie down and press on the area for 15 minutes to try to stop it^[7].

Any bleeding or swelling at the biopsy site should be reported to healthcare providers. Shortness of breath or unusual chest pain immediately after a biopsy may be signs of a complication and should be reported promptly^[3].

Risks and complications

The risk of major cardiac complications from a heart biopsy is operator dependent and less than 1% in experienced centers^[13]. The risks are considered moderate and include^[2]:

• Blood clots
• Bleeding from the biopsy site
• Cardiac arrhythmias (irregular heartbeats)
• Infection
• Injury to the recurrent laryngeal nerve
• Injury to the vein or artery
• Pneumothorax (collapsed lung)
• Rupture of the heart (very rare)
• Tricuspid regurgitation (leaking of the heart valve)

People with certain health conditions may have an increased risk of complications and should discuss with their healthcare provider whether they are good candidates for the procedure^[1].