Endomyocardial biopsy in children on cardiac extracorporeal support

  • Dr Nitha Naqvi, Great Ormond Street Hospital For Sick Children, London, United Kingdom
  • Dr Sachin Khambadkone, Great Ormond Street Hospital For Sick Children, London, United Kingdom
  • Dr Phillip Rees, Great Ormond Street Hospital For Sick Children, London, United Kingdom
  • Dr Michael Burch, Great Ormond Street Hospital For Sick Children, London, United Kingdom
  • Dr Michael Ashworth, Great Ormond Street Hospital For Sick Children, London, United Kingdom
  • Dr Robert Yates, Great Ormond Street Hospital For Sick Children, London, United Kingdom
  • Dr Kate Brown, Great Ormond Street Hospital For Sick Children, London, United Kingdom
  • Dr Graham Derrick, Great Ormond Street Hospital For Sick Children, London, United Kingdom

    • Objectives: To investigate whether endomyocardial biopsy in children on ECMO, performed at the time of decompressing balloon atrial septostomy (BAS), is safe and useful for management and prognosis.

    Methods: Transluminal ventricular biopsy was performed in a cohort of children on cardiac ECMO support at the time of BAS. Echocardiographically guided biopsies were taken, using modified biopsy forceps and sheath. The left ventricle (LV) was sampled by trans-septal approach. Right ventricular (RV) biopsies were taken when a safe approach to LV sampling was not technically possible.

    Results: Median age was 9.5 years (range 5 months-14.4 yrs) and median weight 22kg (range 7-52kg). Seventeen patients underwent attempted biopsy (12 LV, 2 RV, 3 unsuccessful) with minimal addition to procedure time (10 minutes) and no biopsy related complications.
    Histology revealed recoverable disease in 7 patients (5 acute myocarditis, 1 acute rejection [previous heart transplant], 1 antiphospholipid syndrome). Probably unrecoverable disease was seen in 4 patients (cardiomyopathy). Non-specific findings were seen in 3 patients, of which myocarditis was subsequently proved in surgical biopsy (1 patient) and post-mortem biopsy (1 patient).
    Results of biopsy helped stratify management strategy into bridge to recovery or bridge to transplantation/withdrawal.

    Conclusions: Endomyocardial biopsy is feasible and safe in children on ECMO cardiac support, with minimal addition to theatre time and resources, and can provide useful information when histological changes are diagnostic. However, care must be taken with the interpretation of non-diagnostic results, since misleading false negatives may be due to patchy myocardial involvement.