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Trans-Septal Myocardial Biopsy in Hypertrophic Cardiomyopathy Using the Liwen Procedure: An Introduction of a Novel Technique

Trans-Septal Myocardial Biopsy in Hypertrophic Cardiomyopathy Using the Liwen Procedure: An... Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 1905184, 5 pages https://doi.org/10.1155/2021/1905184 Research Article Trans-Septal Myocardial Biopsy in Hypertrophic Cardiomyopathy Using the Liwen Procedure: An Introduction of a Novel Technique 1,2 1 1 1 1 1 1 Chao Han, Mengyao Zhou, Rui Hu, Bo Wang, Lei Zuo, Jing Li, Shengjun Ta, 3 1 2 1 David H. Hsi , Jiani Liu, Lichun Wei , and Liwen Liu Department of Ultrasound, Xijing Hypertrophic Cardiomyopathy Center, Xijing Hospital, Fourth Military Medical University, Xi’an, Shannxi, China Department of Radiation Oncology, Xijing Hypertrophic Cardiomyopathy Center, Xijing Hospital, Fourth Military Medical University, Xi’an, Shannxi, China Heart & Vascular Institute, Stamford Hospital, Stamford, CT, USA Correspondence should be addressed to Lichun Wei; weilichun@fmmu.edu.cn and Liwen Liu; liuliwen@fmmu.edu.cn Received 6 July 2020; Revised 27 September 2020; Accepted 28 January 2021; Published 10 February 2021 Academic Editor: Martin J. Swaans Copyright © 2021 Chao Han et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. +e purpose of this study was to evaluate the feasibility and safety of myocardial biopsy using a new approach, the Liwen procedure. Background. Myocardial biopsy is essential when other methods could not differentiate other etiologies from hy- pertrophic obstructive cardiomyopathy (HOCM). Our previous work using intramyocardial radiofrequency ablation for hy- pertrophic obstructive cardiomyopathy (Liwen procedure) may provide another approach to obtain the myocardial samples. Method. Seventeen patients with HOCM were enrolled for biopsies through percutaneously accessed intramyocardial septum and evaluated possible complications. Results. We obtained 31 specimens from 17 patients with a success rate of sample acquisition 100.0%. +e number of myocardial samples taken per patient was 1.8± 0.8, and the average length of all samples was 16.7± 5.6 mm which could be used for pathological diagnosis. +e complications included pericardial effusion with and without tamponade in one patient (5.9%), and no incidence of nonsustained and sustained ventricular tachycardia, conduction abnormity, perforation, stroke, and pneumothorax. +e inhospital and 30-day mortality was 0%. Conclusion. +is study has shown that myocardial biopsy of the Liwen procedure is relatively safe and technically feasible with adequate tissue sampling, which may help pathological diagnosis and further research of HOCM of diverse etiologies. +is trial is registered with NCT04355260. We developed myocardial biopsy needle of the Liwen 1. Introduction procedure. Seventeen patients with HOCM were enrolled for the Myocardial biopsy should be considered when the results of procedure. We documented biopsy results and complications. other clinical assessments suggest myocardial infiltration, inflammation, or storage disease that cannot be confirmed 2. Materials and Methods from hypertrophic obstructive cardiomyopathy (HOCM) 2.1. Patient Population. +e Institutional Ethics Committee [1–3]. Generally, endomyocardial biopsy (EMB) sampled the of Xijing Hospital approved the procedure, which was per- subendocardial region of the right interventricular septum formed in accordance with the ethical standards of the and the specimens. Declaration of Helsinki. All patients registered at clinicaltrials. Our previous study on the Liwen procedure, which is a gov (NCT04355260) and signed informed consent to proceed nonsurgical approach for percutaneous intramyocardial with LMB. septal ablation treating HOCM, may provide a new tech- nique for myocardial biopsy [4, 5]. Myocardial biopsy of the Liwen procedure (LMB) could obtain the specimens before 2.2. Equipment. Puncture sheath and cardiac biopsy needle the radiofrequency ablation. (Figure 1) were designed and manufactured by Hangzhou 2 Journal of Interventional Cardiology (a) (b) Figure 1: Myocardial biopsy needle of the Liwen procedure. +e biopsy needles were 1.27 mm in diameter with adjustable front-end lengths of 10 mm and 20 mm, respectively. (a) Cardiac puncture sheath. (b) Cardiac biopsy needle. Nuocheng Medical Company. +e biopsy system can be 3.2. Liwen Myocardial Biopsy (LMB) Results. We obtained 31 used multiple times. Cardiac biopsy needle is 1.27 mm in specimens from 17 patients with successful sample acqui- sition in all patients (Table 2). +e number of myocardial diameter. +e front-end biopsy segment is adjustable, with lengths of 10 mm and 20 mm, respectively. Transthoracic samples taken per patient was 1.8± 0.8, the average tissue echocardiography (TTE) guidance was performed with the length was 16.7± 5.6 mm, and the diameter was about EPIQ 7C Ultrasound System (Philips Medical Systems, 1.0 mm. +e specimens were obtained on the first attempt Bothell, Washington) with a 1.0- to 5.0-MHz transducer. and were in the shape of red thin filaments (Figure 3). 2.3. Procedure. After general anesthesia, the patient was 3.3. Complications. Pericardial effusion occurred in the placed in the left semidecumbent position to fully expose the eighth patient after the biopsy and was drained by percu- precordial area. Electrocardiogram tracing, blood pressure, taneous catheter for total volume of about 100 ml. No pa- blood oxygen levels, and central venous pressure were tients experienced pericardial tamponade, nonsustained or monitored throughout the operation. TTE-guided LMB is sustained ventricular tachycardia, conduction abnormity, shown in Figure 2. Under the guidance of echocardiography, perforation, stroke, and pneumothorax. No patients died in the puncture point was located at the apex of the heart, and hospital and during the 30 days after biopsies (Table 2). the guide line was along the long axis of the interventricular septum. First, the puncture sheath was inserted into the 3.4. Pathology Diagnosis. Myocytes showed hypertrophy hypertrophied ventricular septum. Next, about 2 cm from with an increase in the transverse diameter and hyper- the predetermined biopsy position, we inserted myocardial chromatic myocyte nuclei with bizarre shapes (Figure 4(a)). biopsy needle into the sheath and pushed the inner core 2 cm Almost all the specimens showed interstitial fibrosis. forward until the inner switch was fired and the inner core Myofiber disarray was not seen in most slides. Furthermore, was automatically obtained with biopsy tissue. After the inflammatory cells or adipocytes infiltration existed in some cardiac biopsy needle was withdrawn to take out the sections (Figures 4(b) and 4(c)). All the slides of Congo red myocardial tissue, ablation needle was then inserted to the staining were negative (Figure 4(d)). same sheath to start myocardial tissue ablation. +e whole process of biopsy or ablation did not enter any cardiac 4. Discussion chamber. We documented the biopsy results, and the pa- tients were followed up for one month. +e method of Liwen myocardial biopsy (LMB) was similar to the percutaneous approach in the early development of myocardial biopsy but obtained tissue samples at the 2.4. Specimens. +e specimens were stained with Hema- intramyocardial septum in patients with HOCM. Percuta- toxylin-Eosin(H-E) and Congo red and analyzed by an neous needle biopsy was first studied by Sutton et al. [6]. +e experienced pathologist. biopsy sites were ventricular free wall, apex [7–9], or septum through the left ventricle [10]. Due to cardiac tamponade 3. Results and pulmonary complication, this procedure was aban- 3.1. Baseline Characteristics. Seventeen patients (mean age, doned in 1980s. LMB was technically feasible obtaining 49.9± 15.2 years; 5 female patients) with HOCM were en- sufficient sample size in all patients. Sutton et al. used the rolled, and the baseline characteristics are shown in Table 1. modified Terry needle to make biopsies on the surface of the +e mean septal thickness was 23.7± 4.6 mm, mean LVOT left ventricle and took 150 biopsy specimens from 54 pa- peak gradient was 134.0± 54.3 mmHg, and mean ejection tients, among which the specimens of 13 patients were not fraction was 58.6± 3.9%. satisfactory to make diagnosis [7]. +e size of samples was Journal of Interventional Cardiology 3 LV AO LA (a) (b) (c) (d) Figure 2: Myocardial biopsy process of the Liwen procedure. Under the guidance of echocardiography, the biopsy needle was inserted into the puncture sheath from the apex to the central septum and took biopsies. (a) LMB illustration. (b) Echocardiographic image during LMB. (c) +e process of LMB. (d) +e biopsy needle with specimen. Table 1: Baseline patient characteristics (n � 17). Table 2: Results and complications of LMB(n � 17). Value Value Demographics Results Age (years) 49.9± 15.2 Number of myocardial samples taken per patient 1.8± 0.8 Male/female 12/5 Number of total myocardial samples/total trials 31/31 Success rate of biopsy (%) 100% Echocardiography Length of samples (mm) 16.7± 5.6 Maximal septal thickness (mm) 23.7± 4.6 LVOT peak gradient (mmHg) 134.0± 54.3 Complications Ejection fraction (%) 58.6± 3.9 Pericardial effusion with tamponade 0 (0%) Pericardial effusion without tamponade 1 (5.9%) LVOT: left ventricular outflow tract. Continuous variables are presented as Nonsustained ventricular tachycardia (≥3 ventricular mean± SD. 0 (0%) complexes) Sustained ventricular tachycardia 0 (%) Cardiac conduction abnormity 0 (0%) Cardiac perforation 0 (0%) 3 ×1 mm. Raffensperger performed percutaneous needle Stroke 0 (0%) biopsies on 48 patients and found that the volume of samples Pneumothorax 0 (0%) was insufficient to allow viral, bacteriological, microscopic, Inhospital and 30-day mortalities 0 (0%) and biochemical analysis [8]. Shirey used thin-walled Sil- Total percentage of complications 5.9% verman needle for the apical left ventricular biopsy in 198 patients and obtained adequate samples measuring 15 ×1 × 1 mm in 192 patients [9]. For our first patient, the length of the LMB was small about 2 ×1 × 1 mm because of pericardial effusion by minimizing the needle movement. the lack of experience by the operator. We obtained tissue +ere were no patients suffered from pericardial tamponade. We did not observe any nonsustained and sustained ven- sample approximately 16.7 ×1 × 1 mm in subsequent pa- tients with 100% success rate. tricular tachycardia, conduction abnormity, perforation, We feel that Liwen myocardial biopsy is relatively safe. stroke, and pneumothorax. One patient had pericardial effusion in a pattern of slow As shown in Figure 2(a), the needle was away from the oozing, not brisk arterial bleeding, and required percuta- conduction system distributed underneath the endocar- neous pericardial drain without further problems. We dium, so no arrhythmia occurred. Under the guidance of an considered the main reason to be excessive movement of the experienced echocardiographer, the biopsy needle did not biopsy needle within the myocardium trying to find the enter any cardiac chamber, and thus, myocardial perforation appropriate position. We need to reduce the occurrence of risk was negligible. 4 Journal of Interventional Cardiology 2cm Figure 3: Biopsy specimens. +e specimens were in the shape of red thin filament. (a) (b) (c) (d) Figure 4: Histopathology changes in HOCM specimens. (a) Myocytes hypertrophy and hyperchromatic nuclei with bizarre shapes. (b) Inflammatory cells infiltration. (c) Adipocyte infiltration. (d) No amyloidosis (H-E staining and Congo red staining 20x). +e H-E and Congo red staining of tissue samples Data Availability showed histopathological characteristics consistent with +e data used to support the findings of this study are hypertrophic cardiomyopathy [11]. +ere was no evidence of available from the corresponding author upon request. cardiac amyloidosis. Conflicts of Interest 5. Conclusions +e authors declare that they have no conflicts of interest. Our study showed that Liwen myocardial biopsy is relatively safe and technically feasible with adequate tissue sampling, Authors’ Contributions which may help pathological diagnosis and further research in HOCM of diverse etiologies. Dr. Chao Han and Mengyao Zhou contributed equally to this work. 6. Limitations Acknowledgments +e study population was small, and the evaluation of the feasibility and safety was preliminary. Further enrollment of +is study was supported by the Disciplinary Boost Program appropriate patients will continue in our HCM center. of Xijing Hospital (grant nos. XJZT18Z03 and XJZT18MJ51); Journal of Interventional Cardiology 5 National Natural Science Foundation of China (grant no.81981755); and Shaanxi Provincial Key Project (grant no. 2018YBXM-SF-12-1). References [1] P. M. Elliott, P. M. Elliott, A. Borger et al., “2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy: the task force for the diagnosis and man- agement of hypertrophic cardiomyopathy of the European society of cardiology (ESC),” European Heart Journal, vol. 35, no. 39, pp. 2733–2779, 2014. [2] O. Leone, J. P. Veinot, A. Angelini et al., “2011 consensus statement on endomyocardial biopsy from the association for European cardiovascular pathology and the society for car- diovascular pathology,” Cardiovascular Pathology, vol. 21, no. 4, pp. 245–274, 2012. [3] L. T. Cooper, K. L. Baughman, A. M. Feldman et al., “+e role of endomyocardial biopsy in the management of cardiovas- cular disease: a scientific statement from the American heart association, the American college of cardiology, and the European society of cardiology endorsed by the heart failure society of America and the heart failure association of the European society of cardiology,” European Heart Journal, vol. 28, no. 24, pp. 3076–3093, 2007. [4] L. Liu, B. Liu, J. Li, and Y. Zhang, “Percutaneous intra- myocardial septal radiofrequency ablation of hypertrophic obstructive cardiomyopathy: a novel minimally invasive treatment for reduction of outflow tract obstruction,” Euro- Intervention, vol. 13, no. 18, pp. e2112–e2113, 2018. [5] L. Liu, J. Li, L. Zuo et al., “Percutaneous intramyocardial septal radiofrequency ablation for hypertrophic obstructive car- diomyopathy,” Journal of the American College of Cardiology, vol. 72, no. 16, pp. 1898–1909, 2018. [6] D. C. Sutton, G. C. Sutton, and G. Kent, “Needle biopsy of the human ventricular myocardium,” Quarterly Bulletin of the Northwestern University Medical School, vol. 30, no. 3, p. 213, [7] D. C. Sutton and G. C. Sutton, “Needle biopsy of the human ventricular myocardium: review of 54 consecutive cases,” American Heart Journal, vol. 60, no. 3, pp. 364–370, 1960. [8] J. Raffensperger, J. F. Driscol, G. C. Sutton, and M. Weinberg, “Myocardial biopsy,” Archives of Surgery, vol. 89, no. 6, pp. 1021–1023, 1964. [9] E. K. Shirey, W. A. Hawk, D. Mukerji, and D. B. Effler, “Percutaneous myocardial biopsy of the left ventricle,” Cir- culation, vol. 46, no. 1, pp. 112–122, 1972. [10] B. Bercu, J. Heinz, A.-S. Choudhry, and P. Cabrera, “Myo- cardial biopsy,” :e American Journal of Cardiology, vol. 14, no. 5, pp. 675–678, 1964. [11] S. E. Hughes, “+e pathology of hypertrophic cardiomyop- athy,” Histopathology, vol. 44, no. 5, pp. 412–427, 2004. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Interventional Cardiology Hindawi Publishing Corporation

Trans-Septal Myocardial Biopsy in Hypertrophic Cardiomyopathy Using the Liwen Procedure: An Introduction of a Novel Technique

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Hindawi Publishing Corporation
Copyright
Copyright © 2021 Chao Han et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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1540-8183
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0896-4327
DOI
10.1155/2021/1905184
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Abstract

Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 1905184, 5 pages https://doi.org/10.1155/2021/1905184 Research Article Trans-Septal Myocardial Biopsy in Hypertrophic Cardiomyopathy Using the Liwen Procedure: An Introduction of a Novel Technique 1,2 1 1 1 1 1 1 Chao Han, Mengyao Zhou, Rui Hu, Bo Wang, Lei Zuo, Jing Li, Shengjun Ta, 3 1 2 1 David H. Hsi , Jiani Liu, Lichun Wei , and Liwen Liu Department of Ultrasound, Xijing Hypertrophic Cardiomyopathy Center, Xijing Hospital, Fourth Military Medical University, Xi’an, Shannxi, China Department of Radiation Oncology, Xijing Hypertrophic Cardiomyopathy Center, Xijing Hospital, Fourth Military Medical University, Xi’an, Shannxi, China Heart & Vascular Institute, Stamford Hospital, Stamford, CT, USA Correspondence should be addressed to Lichun Wei; weilichun@fmmu.edu.cn and Liwen Liu; liuliwen@fmmu.edu.cn Received 6 July 2020; Revised 27 September 2020; Accepted 28 January 2021; Published 10 February 2021 Academic Editor: Martin J. Swaans Copyright © 2021 Chao Han et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. +e purpose of this study was to evaluate the feasibility and safety of myocardial biopsy using a new approach, the Liwen procedure. Background. Myocardial biopsy is essential when other methods could not differentiate other etiologies from hy- pertrophic obstructive cardiomyopathy (HOCM). Our previous work using intramyocardial radiofrequency ablation for hy- pertrophic obstructive cardiomyopathy (Liwen procedure) may provide another approach to obtain the myocardial samples. Method. Seventeen patients with HOCM were enrolled for biopsies through percutaneously accessed intramyocardial septum and evaluated possible complications. Results. We obtained 31 specimens from 17 patients with a success rate of sample acquisition 100.0%. +e number of myocardial samples taken per patient was 1.8± 0.8, and the average length of all samples was 16.7± 5.6 mm which could be used for pathological diagnosis. +e complications included pericardial effusion with and without tamponade in one patient (5.9%), and no incidence of nonsustained and sustained ventricular tachycardia, conduction abnormity, perforation, stroke, and pneumothorax. +e inhospital and 30-day mortality was 0%. Conclusion. +is study has shown that myocardial biopsy of the Liwen procedure is relatively safe and technically feasible with adequate tissue sampling, which may help pathological diagnosis and further research of HOCM of diverse etiologies. +is trial is registered with NCT04355260. We developed myocardial biopsy needle of the Liwen 1. Introduction procedure. Seventeen patients with HOCM were enrolled for the Myocardial biopsy should be considered when the results of procedure. We documented biopsy results and complications. other clinical assessments suggest myocardial infiltration, inflammation, or storage disease that cannot be confirmed 2. Materials and Methods from hypertrophic obstructive cardiomyopathy (HOCM) 2.1. Patient Population. +e Institutional Ethics Committee [1–3]. Generally, endomyocardial biopsy (EMB) sampled the of Xijing Hospital approved the procedure, which was per- subendocardial region of the right interventricular septum formed in accordance with the ethical standards of the and the specimens. Declaration of Helsinki. All patients registered at clinicaltrials. Our previous study on the Liwen procedure, which is a gov (NCT04355260) and signed informed consent to proceed nonsurgical approach for percutaneous intramyocardial with LMB. septal ablation treating HOCM, may provide a new tech- nique for myocardial biopsy [4, 5]. Myocardial biopsy of the Liwen procedure (LMB) could obtain the specimens before 2.2. Equipment. Puncture sheath and cardiac biopsy needle the radiofrequency ablation. (Figure 1) were designed and manufactured by Hangzhou 2 Journal of Interventional Cardiology (a) (b) Figure 1: Myocardial biopsy needle of the Liwen procedure. +e biopsy needles were 1.27 mm in diameter with adjustable front-end lengths of 10 mm and 20 mm, respectively. (a) Cardiac puncture sheath. (b) Cardiac biopsy needle. Nuocheng Medical Company. +e biopsy system can be 3.2. Liwen Myocardial Biopsy (LMB) Results. We obtained 31 used multiple times. Cardiac biopsy needle is 1.27 mm in specimens from 17 patients with successful sample acqui- sition in all patients (Table 2). +e number of myocardial diameter. +e front-end biopsy segment is adjustable, with lengths of 10 mm and 20 mm, respectively. Transthoracic samples taken per patient was 1.8± 0.8, the average tissue echocardiography (TTE) guidance was performed with the length was 16.7± 5.6 mm, and the diameter was about EPIQ 7C Ultrasound System (Philips Medical Systems, 1.0 mm. +e specimens were obtained on the first attempt Bothell, Washington) with a 1.0- to 5.0-MHz transducer. and were in the shape of red thin filaments (Figure 3). 2.3. Procedure. After general anesthesia, the patient was 3.3. Complications. Pericardial effusion occurred in the placed in the left semidecumbent position to fully expose the eighth patient after the biopsy and was drained by percu- precordial area. Electrocardiogram tracing, blood pressure, taneous catheter for total volume of about 100 ml. No pa- blood oxygen levels, and central venous pressure were tients experienced pericardial tamponade, nonsustained or monitored throughout the operation. TTE-guided LMB is sustained ventricular tachycardia, conduction abnormity, shown in Figure 2. Under the guidance of echocardiography, perforation, stroke, and pneumothorax. No patients died in the puncture point was located at the apex of the heart, and hospital and during the 30 days after biopsies (Table 2). the guide line was along the long axis of the interventricular septum. First, the puncture sheath was inserted into the 3.4. Pathology Diagnosis. Myocytes showed hypertrophy hypertrophied ventricular septum. Next, about 2 cm from with an increase in the transverse diameter and hyper- the predetermined biopsy position, we inserted myocardial chromatic myocyte nuclei with bizarre shapes (Figure 4(a)). biopsy needle into the sheath and pushed the inner core 2 cm Almost all the specimens showed interstitial fibrosis. forward until the inner switch was fired and the inner core Myofiber disarray was not seen in most slides. Furthermore, was automatically obtained with biopsy tissue. After the inflammatory cells or adipocytes infiltration existed in some cardiac biopsy needle was withdrawn to take out the sections (Figures 4(b) and 4(c)). All the slides of Congo red myocardial tissue, ablation needle was then inserted to the staining were negative (Figure 4(d)). same sheath to start myocardial tissue ablation. +e whole process of biopsy or ablation did not enter any cardiac 4. Discussion chamber. We documented the biopsy results, and the pa- tients were followed up for one month. +e method of Liwen myocardial biopsy (LMB) was similar to the percutaneous approach in the early development of myocardial biopsy but obtained tissue samples at the 2.4. Specimens. +e specimens were stained with Hema- intramyocardial septum in patients with HOCM. Percuta- toxylin-Eosin(H-E) and Congo red and analyzed by an neous needle biopsy was first studied by Sutton et al. [6]. +e experienced pathologist. biopsy sites were ventricular free wall, apex [7–9], or septum through the left ventricle [10]. Due to cardiac tamponade 3. Results and pulmonary complication, this procedure was aban- 3.1. Baseline Characteristics. Seventeen patients (mean age, doned in 1980s. LMB was technically feasible obtaining 49.9± 15.2 years; 5 female patients) with HOCM were en- sufficient sample size in all patients. Sutton et al. used the rolled, and the baseline characteristics are shown in Table 1. modified Terry needle to make biopsies on the surface of the +e mean septal thickness was 23.7± 4.6 mm, mean LVOT left ventricle and took 150 biopsy specimens from 54 pa- peak gradient was 134.0± 54.3 mmHg, and mean ejection tients, among which the specimens of 13 patients were not fraction was 58.6± 3.9%. satisfactory to make diagnosis [7]. +e size of samples was Journal of Interventional Cardiology 3 LV AO LA (a) (b) (c) (d) Figure 2: Myocardial biopsy process of the Liwen procedure. Under the guidance of echocardiography, the biopsy needle was inserted into the puncture sheath from the apex to the central septum and took biopsies. (a) LMB illustration. (b) Echocardiographic image during LMB. (c) +e process of LMB. (d) +e biopsy needle with specimen. Table 1: Baseline patient characteristics (n � 17). Table 2: Results and complications of LMB(n � 17). Value Value Demographics Results Age (years) 49.9± 15.2 Number of myocardial samples taken per patient 1.8± 0.8 Male/female 12/5 Number of total myocardial samples/total trials 31/31 Success rate of biopsy (%) 100% Echocardiography Length of samples (mm) 16.7± 5.6 Maximal septal thickness (mm) 23.7± 4.6 LVOT peak gradient (mmHg) 134.0± 54.3 Complications Ejection fraction (%) 58.6± 3.9 Pericardial effusion with tamponade 0 (0%) Pericardial effusion without tamponade 1 (5.9%) LVOT: left ventricular outflow tract. Continuous variables are presented as Nonsustained ventricular tachycardia (≥3 ventricular mean± SD. 0 (0%) complexes) Sustained ventricular tachycardia 0 (%) Cardiac conduction abnormity 0 (0%) Cardiac perforation 0 (0%) 3 ×1 mm. Raffensperger performed percutaneous needle Stroke 0 (0%) biopsies on 48 patients and found that the volume of samples Pneumothorax 0 (0%) was insufficient to allow viral, bacteriological, microscopic, Inhospital and 30-day mortalities 0 (0%) and biochemical analysis [8]. Shirey used thin-walled Sil- Total percentage of complications 5.9% verman needle for the apical left ventricular biopsy in 198 patients and obtained adequate samples measuring 15 ×1 × 1 mm in 192 patients [9]. For our first patient, the length of the LMB was small about 2 ×1 × 1 mm because of pericardial effusion by minimizing the needle movement. the lack of experience by the operator. We obtained tissue +ere were no patients suffered from pericardial tamponade. We did not observe any nonsustained and sustained ven- sample approximately 16.7 ×1 × 1 mm in subsequent pa- tients with 100% success rate. tricular tachycardia, conduction abnormity, perforation, We feel that Liwen myocardial biopsy is relatively safe. stroke, and pneumothorax. One patient had pericardial effusion in a pattern of slow As shown in Figure 2(a), the needle was away from the oozing, not brisk arterial bleeding, and required percuta- conduction system distributed underneath the endocar- neous pericardial drain without further problems. We dium, so no arrhythmia occurred. Under the guidance of an considered the main reason to be excessive movement of the experienced echocardiographer, the biopsy needle did not biopsy needle within the myocardium trying to find the enter any cardiac chamber, and thus, myocardial perforation appropriate position. We need to reduce the occurrence of risk was negligible. 4 Journal of Interventional Cardiology 2cm Figure 3: Biopsy specimens. +e specimens were in the shape of red thin filament. (a) (b) (c) (d) Figure 4: Histopathology changes in HOCM specimens. (a) Myocytes hypertrophy and hyperchromatic nuclei with bizarre shapes. (b) Inflammatory cells infiltration. (c) Adipocyte infiltration. (d) No amyloidosis (H-E staining and Congo red staining 20x). +e H-E and Congo red staining of tissue samples Data Availability showed histopathological characteristics consistent with +e data used to support the findings of this study are hypertrophic cardiomyopathy [11]. +ere was no evidence of available from the corresponding author upon request. cardiac amyloidosis. Conflicts of Interest 5. Conclusions +e authors declare that they have no conflicts of interest. Our study showed that Liwen myocardial biopsy is relatively safe and technically feasible with adequate tissue sampling, Authors’ Contributions which may help pathological diagnosis and further research in HOCM of diverse etiologies. Dr. Chao Han and Mengyao Zhou contributed equally to this work. 6. Limitations Acknowledgments +e study population was small, and the evaluation of the feasibility and safety was preliminary. Further enrollment of +is study was supported by the Disciplinary Boost Program appropriate patients will continue in our HCM center. of Xijing Hospital (grant nos. XJZT18Z03 and XJZT18MJ51); Journal of Interventional Cardiology 5 National Natural Science Foundation of China (grant no.81981755); and Shaanxi Provincial Key Project (grant no. 2018YBXM-SF-12-1). References [1] P. M. Elliott, P. M. Elliott, A. Borger et al., “2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy: the task force for the diagnosis and man- agement of hypertrophic cardiomyopathy of the European society of cardiology (ESC),” European Heart Journal, vol. 35, no. 39, pp. 2733–2779, 2014. [2] O. Leone, J. P. Veinot, A. Angelini et al., “2011 consensus statement on endomyocardial biopsy from the association for European cardiovascular pathology and the society for car- diovascular pathology,” Cardiovascular Pathology, vol. 21, no. 4, pp. 245–274, 2012. [3] L. T. Cooper, K. L. Baughman, A. M. Feldman et al., “+e role of endomyocardial biopsy in the management of cardiovas- cular disease: a scientific statement from the American heart association, the American college of cardiology, and the European society of cardiology endorsed by the heart failure society of America and the heart failure association of the European society of cardiology,” European Heart Journal, vol. 28, no. 24, pp. 3076–3093, 2007. [4] L. Liu, B. Liu, J. Li, and Y. Zhang, “Percutaneous intra- myocardial septal radiofrequency ablation of hypertrophic obstructive cardiomyopathy: a novel minimally invasive treatment for reduction of outflow tract obstruction,” Euro- Intervention, vol. 13, no. 18, pp. e2112–e2113, 2018. [5] L. Liu, J. Li, L. Zuo et al., “Percutaneous intramyocardial septal radiofrequency ablation for hypertrophic obstructive car- diomyopathy,” Journal of the American College of Cardiology, vol. 72, no. 16, pp. 1898–1909, 2018. [6] D. C. Sutton, G. C. Sutton, and G. Kent, “Needle biopsy of the human ventricular myocardium,” Quarterly Bulletin of the Northwestern University Medical School, vol. 30, no. 3, p. 213, [7] D. C. Sutton and G. C. Sutton, “Needle biopsy of the human ventricular myocardium: review of 54 consecutive cases,” American Heart Journal, vol. 60, no. 3, pp. 364–370, 1960. [8] J. Raffensperger, J. F. Driscol, G. C. Sutton, and M. Weinberg, “Myocardial biopsy,” Archives of Surgery, vol. 89, no. 6, pp. 1021–1023, 1964. [9] E. K. Shirey, W. A. Hawk, D. Mukerji, and D. B. Effler, “Percutaneous myocardial biopsy of the left ventricle,” Cir- culation, vol. 46, no. 1, pp. 112–122, 1972. [10] B. Bercu, J. Heinz, A.-S. Choudhry, and P. Cabrera, “Myo- cardial biopsy,” :e American Journal of Cardiology, vol. 14, no. 5, pp. 675–678, 1964. [11] S. E. Hughes, “+e pathology of hypertrophic cardiomyop- athy,” Histopathology, vol. 44, no. 5, pp. 412–427, 2004.

Journal

Journal of Interventional CardiologyHindawi Publishing Corporation

Published: Feb 10, 2021

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