Comparison of fluoroscopic versus real-time three-dimensional transthoracic echocardiographic guidance of endomyocardial biopsies

Aims Fluoroscopic-guided right ventricular (RV) endomyocardial biopsy (EMBx) is the conventional method for obtaining myocardial samples to assess for rejection following heart transplantation. This study was designed to assess the feasibility and accuracy of guiding RV sheath and bioptome tip position using real-time three-dimensional echocardiography (RT3DE). Methods and results Forty EMBx procedures were performed in 21 patients. Five procedures were in a native heart and 35 were performed following cardiac transplantation. A RV long sheath was positioned toward the mid to distal interventricular septum using fluoroscopy. RT3DE was used to correlate sheath tip position with fluoroscopic position. Bioptome tip visualization and position against the endocardium was assessed using RT3DE. Sheath tip location was repositioned in 18 cases (46) following assessment using RT3DE, due to alignment toward the apex (9) and mid (5) or distal RV (4) free wall. The bioptome tip could be clearly visualized using RT3DE in 83 of passes. In 35 of passes, the bioptome tip was repositioned using RT3DE guidance to improve the sampling site. Conclusion RT3DE-guided EMBx was feasible in the majority of patients and resulted in sheath repositioning in 46 of patients and bioptome tip reorientation in 35 of cases.