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CHAPTER 31
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Transcatheter Biopsy for
Intracardiac Masses
Gautam Reddy Charanjit Rihal
Introduction
Intracardiac masses (ICMs) are rare entities in clinical practice. The differential diagnosis
is wide, including pathologies such as infective, thrombotic, neoplastic, autoimmune, iatrogenic, or hamartomatous lesions.
nario, such as valvar vegetations in infective endocarditis or appendage thrombus in atrial
fibrillation, they can present a significant diagnostic challenge. Although imaging modalities like transthoracic echocardiography (TTE), transesophageal echocardiography
(TEE), computed tomography (CT), magnetic resonance imaging (MRI), and positron
emission tomography (PET) can be used to suggest a diagnosis, they may not be conclu-
2
sive.
A histopathologic diagnosis may significantly change clinical decision-making and
treatment options. This is especially true for cancer therapies, which may require molecular
targeting and cause systemic toxicity.
The heart presents significant barriers to retrieving tissue for diagnosis. It sits deep in the
mediastinum surrounded by vital organs and is in constant motion with every heartbeat. This
makes CT- or MRI-guided needle biopsy approaches difficult or impossible. Cardiac surgeons
can biopsy these masses, but the patient must undergo general anesthesia, cardiopulmonary bypass, median sternotomy, cardiac reconstruction, wound healing, and general rehabilitation, all of
which come with a risk of morbidity and mortality.
compressive symptoms necessitating immediate excision, transcatheter biopsy (TCB) can offer a
minimally invasive route to a histopathologic diagnosis.
1
Unless clearly associated with a specific clinical sce-
3
For intracardiac lesions that do not cause
AHA Guidelines
Fulminant heart failure ,2 weeks duration I B
Heart failure of 2 weeks to 3 months duration with dilated left ventricle
(LV) with ventricular arrhythmias or atrioventricular (AV) block or refractory to conventional therapy
Dilated LV with ventricular arrhythmias or AV block or refractory to
conventional therapy of .3 months duration
Selected cardiac masses IIa C
Dilated LV with eosinophilia IIa C
Restrictive cardiomyopathy or suspected anthracycline toxicity, not
diagnosed by imaging
Cardiac transplantation surveillance Not covered by
374
I B
IIa C
IIa C
guidelines
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Selection
The patient who undergoes TCB for ICM should meet several criteria as described in the
following sections.
CLINICAL CONSIDERATIONS
First, there must be concrete clinical benefit in performing biopsy of an ICM to establish histopathologic diagnosis. The mass must remain undiagnosed despite noninvasive study. Simple entities like endocarditic vegetations and appendage thrombus can be diagnosed with reasonable
certainty and treated with standard therapies after echocardiographic diagnosis—such lesions
should not be biopsied unless the clinical picture is unclear. The specific benefit of histopathologic diagnosis is either an increased accuracy of molecular targeting, such as ligand-specific
chemotherapy for cancer metastases, or the obviation of cardiac surgery for compressive lesions
that can be resolved without excision, such as primary cardiac lymphoma. There is also a role for
establishing a histopathologic diagnosis to guide an informed transition to palliative care for
patients with incurable pathology.
TECHNICAL CONSIDERATIONS
Second, there must be a focal ICM in the heart accessible by the intravascular route or through the
anterior chest wall. The lesion should be continuously visible by echocardiography, either TTE or
TEE, which is critical for procedural guidance. Lesion size must be sufficient to allow engagement
by the biopsy equipment, but there is no concrete size at which biopsy must be abandoned, and lesion
morphology will also affect the likely success of a biopsy. Masses that are sessile and circumscribed
are more likely to be engaged with biopsy equipment compared with lesions that are pedunculated
and filamentous. Masses that are highly mobile are more difficult to biopsy. The location of the lesion
in the cardiovascular system should be considered. As with any structural procedure, relational
anatomy will dictate expected complications. Lesion proximity to structures such as the sinoatrial
node, AV node, His bundle, and prosthetic or native valve leaflets should raise concern. Right-sided
masses are more accessible and carry a lower risk of systemic thromboembolism compared with leftsided masses. Mass lesions located on the interatrial and interventricular septum present a lower risk
of cardiac perforation and pericardial tamponade compared with free wall lesions.
Planning
Planning considerations should include vascular access selection, mass visualization, mass navigation, bioptome delivery, and access site closure. Reconstruction of CT or MRI in 3D allows for
a better understanding of mass size, mass characteristics, surrounding relations, access route
length, and working angulations, and the potential for complications and available imaging
should be thoroughly studied before biopsy. Because all access considerations are dependent on
the size of the biopsy device to be used, we will start with a discussion of biopsy equipment.
BIOPSY EQUIPMENT
Medical tools to remotely retrieve cardiac tissue include the standard endomyocardial bioptome
( Jaws, Argon Medical, Frisco TX), hepatic side-cutting needles (BX Needle, Cook Medical,
Bloomington, IN), and gastrointestinal biopsy forceps (EndoJaw, Olympus Medical, Tokyo, JP)
(Fig. 31.1). All devices are compatible with an 8F hemostatic sheath. A complex avulsion
approach with a combination of a loop snare to electrosurgically sever the base of a mass
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A
B
Fig. 31.1 Images of jaw-type bioptome and side-cutting needle. (A) Flexible endomyocardial bioptome
with articulated jaws. A hand-operated lever on the opposite end controls opening. (B) Flexible side-cutting
needle normally used for transjugular liver biopsies. This can be adapted for percutaneous intracardiac biopsies. (Reproduced with permission from Reddy G, Maor E, Bois MC, et al. Percutaneous transcatheter biopsy
for intracardiac mass diagnosis. EuroIntervention. 2017;13[12]:e1436-e1443).
(Gooseneck, Medtronic, Minneapolis, MN) and a trileaflet snare (EN Snare, Merit Medical,
South Jordan, UT) to retrieve the mass can be considered in sites where embolic potential is
limited. The sheath size should be large enough to accommodate the size of the mass in order
to extract it. We have performed a single biopsy of an anterior cardiac mass via the percutaneous
transthoracic approach using a Jamshidi bone marrow biopsy needle (Beckton Dickinson,
Franklin Lakes, NJ), but this is a high-risk procedure and may not be replicable at other centers.
Biopsy equipment selection should be tailored to the lesion. For masses that are thought to be
relatively soft based on imaging characteristics, the endomyocardial bioptome allows for targeted
lesion sampling without damage to surrounding structures. In cases where the mass is thought to
be relatively hard, contained in a fibrous pellicle, covered with chronic thrombus, and has enough
noncritical surrounding tissue to allow for biopsy-targeting errors, a side-cutting needle or
EndoJaw biopsy forceps can be considered.
The Quick-Core side-cutting needles are designed for transjugular hepatic and renal biopsies
in coagulopathic patients. The needle throw is 2 cm, and one should make sure that there is
enough mass length to accommodate the full length of the needle without penetration into other
structures behind it. Operators should note that sheath length may be a limiting factor when
these needles are used. The transjugular hepatic biopsy needle has a total length of 50 cm. It has
a sharp tip that will not traverse standard hemostatic sheaths. A 7F metal introducer tube is included and must be used to avoid piercing sheaths with the needle while inserting it into the
body. The transjugular renal biopsy needle has a length of 70 cm. The added length may be advantageous for antegrade transseptal or retrograde aortic procedures. Although it is also supplied
with a 7F metal introducer, it has a blunt tip that can be directly introduced into hemostatic
sheaths without risk of traversing the sheath wall. The main reason to use a liver biopsy needle,
other than anatomic accessibility, is that ICMs, particularly tumors, are often encapsulated, and
the standard jaws of our bioptomes will not penetrate this type of lesion.
The EndoJaw biopsy forceps are designed for remote biopsy of gastrointestinal lesions
through endoscope lumens. The standard version has a 2-mm diameter and requires an 8F
sheath. It has three traumatic teeth on either side and may avulse a large portion of the mass
because of the force with which tissue can be gripped. Masses located close to valves should be
avoided with this approach. Serial use of a variety of biopsy devices may allow sampling at different
mass depths. It is unknown if this increases diagnostic yield.
4
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ACCESS SIZING
Sheath size is dependent on the biopsy equipment chosen. We recommend the use of a long,
braided straight or curved sheath to avoid having to steer through the femoral venous vasculature
with the biopsy instrument. Embedding the sheath into the mass allows rapid repeat sampling
with the biopsy instrument without have to navigate each time. A steerable sheath (Agilis NXT,
Abbott Vascular, St. Paul, MN) can be useful in tortuous anatomies or angulated mass locations.
A combination telescoping technique using a standard vascular sheath and a large-bore coronary
guiding catheter might be an alternative if a steerable sheath is not readily available. Care should
be taken to ensure that the selected biopsy equipment will fit through the selected sheath before
starting the procedure. Suture-mediated closure devices (Perclose Proglide, Abbott Vascular, St.
Paul, MN) can be considered for hemostatic closure when large-bore sheaths are used. In cases
where intracardiac echocardiogram (ICE) is required for mass visualization and biopsy guidance,
a separate vascular access sheath should be inserted.
MASS VISUALIZATION
Echocardiographic guidance is crucial for accurate mass biopsy and avoidance of complications.
Either TTE or TEE should be used in all cases. Visualization of atrial masses may be limited
with 3D TTE, which is better suited for ventricular mass biopsy. TEE with 3D is the modality
of choice for atrial mass biopsy, and can also be used to guide transseptal puncture. TEE for the
duration of the biopsy will typically require general anesthesia, and preprocedure consultation
with cardiac anesthetists should be obtained. The presence of a trained structural imaging cardi-
ologist to guide the procedure can be invaluable. ICE alone can be used for biopsy of large atrial
masses, but a 3D understanding of ICM location and its relationship to the tip of the bioptome
is necessary for effective imaging and may be challenging. Supplemental imaging with TTE or
TEE during the case is recommended in this situation.
BIOPTOME DELIVERY
Right-Sided Masses
For masses located in the vena cavae, right atrium, and right ventricle, access is relatively
straightforward. The internal jugular vein (IJ) or femoral vein (FV) are recommended access
sites. The IJ route allows for natural steering into the right ventricle or pulmonary artery,
akin to a Swan-Ganz catheter. It allows for better bioptome control given the smoother ap-
proach and shorter distances, especially when accessing masses located in the right ventricle
or pulmonary artery. The ergonomics of catheter management from the IJ are challenging
compared with the FV approach. Right-sided masses are well visualized with TTE, unless
they are located in the interatrial septum, in which case TEE is recommended. Care should
be taken to avoid the tricuspid valve leaflets and subvalvular chordae when performing the
biopsy. We recommend using standard-dose anticoagulation for these procedures (iStat
ACT 200-300s).
Left-Sided Masses
Potential access routes include antegrade transseptal (TS) and retrograde aortic (RA). The TS
approach is well suited to a mass located in the left atrium and basal-to-mid ventricle. In these
locations, care should be taken to avoid the pulmonary vein ostia and mitral valve chordae during
bioptome operation. The RA approach is better for apical left ventricular masses. We do not
recommend its use for other ventricular locations given interference with mitral chordae and dif-
ficulties with steering once inside the ventricle. Potential complications include in situ thrombus
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A B D
E
Fig. 31.2 Percutaneous transthoracic biopsy of right ventricular mass. (A) Cardiac CT showing the
heterogeneously enhancing mass in the anterior wall of the right ventricle (arrow). (B) Cardiac MRI showing
transmural ventricular extension of the mass (arrow). (C) Intraprocedural TTE showing the cavitating mass in
the free wall of the right ventricle (arrow). (D) Intraprocedural TTE showing the bioptome shaft in the right
ventricle (arrowheads) and bioptome head (arrow) contacting the mass. (E) Representative image of a Jamshidi bone marrow biopsy needle used for percutaneous transthoracic biopsy of the right ventricular mass.
(F) Photomicrographs of the biopsy specimen show multiple fragments of dense, granulomatous inflammation
involving the myocardium (hematoxylin and eosin, 4003 original magnification). Grocott’s methenamine silver
stain highlights rare septate branching hyphae, morphologically consistent with Aspergillus species (4003 original
magnification) (arrow). Infiltrating transmural mass seen in situ (G) and after excision by the cardiovascular surgical team (H). CT, Computed tomography; LV, left ventricle; MRI, magnetic resonance imaging; RV, right ventricle.
(Reproduced with permission from Reddy G, Maor E, Bois MC, et al. Percutaneous transcatheter biopsy for
intracardiac mass diagnosis. EuroIntervention. 2017;13[12]:e1436-e1443).
F
F ED
C
C
D
formation and systemic embolization. Carotid filters such as a multivessel protection device
(Sentinel, Claret Medical, Santa Rosa, CA) or multiple basket filters (Spider FX, Medtronic,
Minneapolis, MN) can be considered. These may not be uniformly protective. The specific risk
of embolization remains unknown. We recommend an in-depth discussion about the risks and
benefits of left-sided mass biopsy with the patient before the procedure. We also recommend
performing such biopsies in locations where neurointerventional assistance for cerebral embolectomy is readily available if required. We recommend high-dose anticoagulation in this setting
(iStat ACT 300-400s), recognizing that the risk of pericardial effusion is increased.
Technique
Careful technique is necessary to yield diagnoses and prevent complications. Like any other
structural procedure, clear lines of communication between operator, imager, and other team
members should be established and maintained throughout.
SHEATH INSERTION and POSITIONING
Once the mass is located on imaging and access is obtained, we recommend a long sheath be
inserted. During sheath insertion in the jugular or femoral veins, care should be taken to avoid
adjacent arterial injury. Ultrasound guidance is recommended for access. If right ventricle (RV)
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Fig. 31.3 Commonly used bioptomes. (A) Single-use 50-cm disposable bioptome with a 2.3 mm tip that
requires a 9F sheath. (B) Endomyocardial biopsy forceps with a 1.8-mm tip that requires a 6F sheath or a
2.3-mm tip that requires a 7F sheath. (C) 7 bioptome, 50 cm and 104 cm, with a 2.3-mm tip that requires a
7F. (D) 8F transseptal sheath when using the longer 7 bioptome through right femoral vein access to improve
tip control and placement. (From From AM, Maleszewsky JJ, Rihal CS. Current status of endomyocardial
biopsy. Mayo Clinic Proc. 2011;86:1095.)
Fig. 31.4 Endomyocardial biopsy under fluoroscopic guidance. The bioptome tip is in the RV with jaws
open, shortly before taking a biopsy specimen. (From Wu AH, Kolias TJ. Cardiac transplantation: Pretransplant
and posttransplant evaluation. In CM Otto, ed. Practice of Clinical Echocardiography. Philadelphia: Elsevier;
2017:577-595).
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Fig. 31.5 Internal jugular approach. The bioptome tip is in the right ventricular apex pointing toward the
ventricular septum. (From Tilkian AG, Daily EK. Cardiovascular Procedures: Diagnostic Techniques and Thera-
peutic Procedures. St. Louis, MO: Mosby; 1986.)
biopsy for surveillance is intended, a precurved sheath, such as the Fast-Cath, may be utilized to
avoid tricuspid valve injury.
The sheath should be navigated as close to the mass as possible. A tip deflector or steerable
sheath might be necessary. Continuous echocardiographic guidance is necessary during this step
to avoid cardiac perforation or damage to other cardiac structures. 3D imaging is especially useful
when a steerable sheath is being used. The primary advantage of having a sheath embedded in
the mass is the ability to rapidly perform serial biopsies with one or more instruments in the same
location, with the potential for deeper penetration into diagnostic tissue after each pass.
BIOPSY TECHNIQUE
Operators aim to both penetrate one site deeply and sample different sites on the mass to increase
diagnostic yield. We recommend that at least 10 samples be taken, if possible, because there is a
correlation between an increasing number of samples and diagnostic yield.
retrieved, they should be sent to the frozen section laboratory in saline for immediate analysis.
This can provide information in minutes as to the diagnostic yield of the specimen, though a
final diagnosis may await detailed analysis with special techniques.
is usually a pellicle of fibrous tissue or thrombotic material that can confound biopsy attempts. If
the frozen section is nondiagnostic, sampling should be repeated until a diagnostic result is obtained, or until the operator feels that further biopsy is futile. It may be necessary to change biopsy locations or biopsy instruments to achieve a diagnostic yield. If the sheath is embedded in
the tissue, it may be periodically aspirated or removed from the body and flushed to see if there
is mass material in the tip.
For RV masses, if the endovascular approach does not work, a transthoracic approach can be
safely employed. Operators should be ready to place a pericardial catheter if necessary.
4
Once the samples are
5
In chronic mass lesions, there
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SAMPLE ANALYSIS
Once diagnostic samples are obtained, they should be sent to the laboratory in saline, formalin,
and other media as appropriate. A discussion should take place before the biopsy, during the likely
diagnoses are discussed and collection media are prepared. Ancillary investigations, such as mo-
lecular staining, flow cytometry, microbial culture, and polymerase chain reaction, may require
specialized collection media. The slides should be reviewed by a cardiac pathologist.
Complications
PROCEDURAL MONITORING
Operators should be vigilant for instrument-induced pericardial effusions and cardiac arrhyth-
mias. Periodic imaging surveillance of the pericardium should be conducted at regular intervals.
Atrial or ventricular tissue contact with the sheath or bioptome may induce sustained arrhythmias
requiring supportive therapy or synchronized cardioversion. In the Mayo Clinic series, arrhyth-
mias were the only major complication noted during biopsy. Hemodynamic compromise without
effusion or arrhythmia should prompt evaluation for unusual complications like pulmonary vein
perforation or AV valve disruption.
Applications
MEDICAL THERAPY
Once a histopathologic diagnosis is obtained, a management strategy can be selected. For ham-
artomas or congenital abnormalities, watchful waiting may be recommended if no compressive
symptoms are noted. Other specific etiologies like thrombus or vegetation can be treated with
directed therapies. The true value of TCB lies in targeted chemotherapy and radiation regimens
for malignant neoplasms. Sensitive hematologic tumors like primary cardiac lymphoma produc-
ing compressive symptoms can resolve in a matter of days. In cases like these, cardiovascular
surgical excision may no longer be needed.
SURGICAL THERAPY
When compressive symptoms exist and the lesion is not reducible with medical therapy, surgical
excision becomes necessary. There is value in establishing a preoperative diagnosis, because this
will dictate utility of neoadjuvant therapies and the extent of resection.
PALLIATIVE CARE
Finally, in patients with large comorbidity burdens who have end-stage cardiac symptoms or ag-
gressive neoplasms, an informed decision can be made based on the histopathologic diagnosis to
transition to palliative care, allowing patients to know their prognosis and avoid futile therapies.
Future
Outside of case reports, limited data exist regarding the utility and safety of TCB of ICMs. The
rare nature of these lesions has confounded attempts to study the procedure. A registry-based
approach may be advisable. Future directions should include better embolic protection for left-
sided biopsies; multimodality imaging overlay between fluoroscopy, echocardiography, CT, and
MRI to better guide these procedures in 3D; and investigation of implantable therapies like
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brachytherapy seeds or pharmaceutical beads that could be delivered by transcatheter means
directly into cardiac masses.
Summary and Take-Home Points
n
TCB for cardiac masses may be safe and feasible. Risks are dependent on the location of
the mass and the surrounding structures.
n
Detailed review of imaging will allow appropriate selection of access route and biopsy tools.
n
Continuous monitoring should be performed during the biopsy because biopsy and cardiac
instrumentation may provoke ventricular or atrial arrhythmias.
n
Multiple biopsies should be taken to increase the diagnostic yield: ideally 10 samples or
more, if possible.
References
1. Roberts WC. Primary and secondary neoplasms of the heart. Am J Cardiol. 1997;80(5):671-682.
2. Araoz PA, Eklund HE, Welch TJ, Breen JF. CT and MR imaging of primary cardiac malignancies. Ra-
diographics. 1999;19(6):1421-1434.
3. Elbardissi AW, Dearani JA, Daly RC, et al. Survival after resection of primary cardiac tumors: A 48-year
experience. Circulation. 2008;118(14 Suppl):S7-S15.
4. Reddy G, Maor E, Bois MC, et al. Percutaneous transcatheter biopsy for intracardiac mass diagnosis.
EuroIntervention. 2017;13(12):e1436-e1443.
5. Winters GL, Hauptman PJ, Jarcho JA, Schoen FJ. Immediate evaluation of endomyocardial biopsies for
clinically suspected rejection after heart transplantation. Circulation. 1994;89(5):2079-2084.
e1
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Abstract: Intracardiac masses are rare and can involve any cardiac chamber or major vessel. The
differential diagnosis includes hundreds of separate entities and can be impossible to establish
without histology. Cardiac surgical excision has remained the mainstay of diagnosis and the only
treatment option for compressive masses. Transcatheter biopsy of intracardiac masses is a
minimally invasive procedure that can establish a histopathologic diagnosis and guide clinical
decision-making without the morbidity and mortality associated with cardiac surgery. This
chapter focuses on the practical aspects of transcatheter biopsy for intracardiac masses and
discusses case selection, procedural planning, sample analysis, and clinical applications for this
diagnostic structural procedure.
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