Transradial Approach for Left Ventricular Endomyocardial Biopsy

doi:10.1016/j.cjca.2018.05.007

Canadian Journal of Cardiology

Volume 34, Issue 10, October 2018, Pages 1283-1288

https://doi.org/10.1016/j.cjca.2018.05.007 Get rights and content

Abstract

Background

Left ventricular endomyocardial biopsy (LV-EMB) may offer a superior diagnostic yield compared with right ventricular endomyocardial biopsy (RV-EMB) in conditions predominantly affecting the LV but is underused compared with RV-EMB. Despite the steep uptake of radial approach in coronary interventions, LV-EMB is usually performed via the femoral artery in contemporary practice. Therefore, the aim of this study was to assess the safety and feasibility of LV-EMB via a transradial approach in a multicentre registry.

Methods

One-hundred and two patients who underwent LV-EMB via transradial approach were included. Clinical characteristics, procedural, safety and feasibility data were evaluated.

Results

LV-EMB was successfully performed via transradial access in 101 (99%) patients. Mild or moderate radial artery spasm occurred in 12 (12%) patients, but only 1 (0.98%) patient required conversion to femoral access due to severe spasm. A total of 80 (78%) patients had LV-EMB via a sheathless guide catheter. Among those, 77 (96.3%) patients had 7.5-French sheathless guides, and 3 (3.8%) patients had 8.5-French sheathless guides inserted. Radial sheaths were used in the remaining 22 patients, with 5-French sheaths in 21 of 22 patients. Heparin was administered to 93.1% of patients at a median dose of 5000 (3000–5000) IU. The remaining patients followed a provisional strategy upon patent hemostasis achievement. No access site-related complications were reported. There were no major complications (pericardial tamponade, life-threatening arrhythmia, cerebrovascular accident or death).

Conclusions

In a population of patients undergoing transradial LV-EMB, the procedural success rate was high and showed an excellent safety profile. Further studies comparing transradial and transfemoral routes may help expand the use of transradial access for LV-EMB.

Résumé

Contexte

La biopsie endomyocardique du ventricule gauche (BEM-VG) peut offrir un rendement diagnostique supérieure à celui de la BEM du ventricule droit (BEM-VD) dans des troubles qui touchent principalement le ventricule gauche (VG), mais est sous-utilisée par rapport à la BEM-VD. Malgré l’augmentation rapide de l’utilisation de la voie radiale dans les interventions coronariennes, la BEM-VG s’effectue en général par l’artère fémorale dans la pratique contemporaine. Par conséquent, l’objectif de cette étude était d’évaluer, à partir d’un registre multicentrique, la sûreté et la faisabilité de la BEM-VG par la voie transradiale.

Méthodologie

Cent deux patients qui avaient subi une BEM-VG par l’approche transradiale ont été inclus. Les caractéristiques cliniques et les données relatives à l’intervention, à l’innocuité et à la faisabilité ont été analysées.

Résultats

La BEM-VG a été effectuée avec succès par la voie transradiale chez 101 (99 %) patients. Spasme radiale légère ou modérée s’est produit chez 12 (12 %) patients, mais la conversion en voie fémorale n’a été nécessaire que chez 1 (0,98 %) patient en raison d’un spasme sévère. Au total, 80 (78 %) patients ont subi une BEM-VG au moyen d’un cathéter guide sans gaine d’introducteur (sheathless). Pour ces interventions, le diamètre externe du guide sans gaine d’introducteur inséré était de 7,5 French chez 77 (96,3 %) patients et de 8,5 French chez 3 (3,8 %) patients. Un introducteur radiale a été utilisé chez les 22 autres patients, d’un diamètre externe de 5 French chez 21 de ces derniers. Une dose médiane de 5000 (3000–5000) unités internationales (UI) d’héparine a été administrée à 93,1 % des patients. Pour les autres patients, une stratégie provisoire a été appliquée en fonction de l’obtention d’une hémostase manifeste. Aucune complication liée à la voie d’accès n’a été rapportée. Il n’y a eu aucune complication majeure (tamponnade péricardique, arythmie potentiellement mortelle, accident vasculaire cérébral ou décès).

Conclusion

Dans une population de patients ayant subi une BEM-VG par la voie transradiale, le taux de succès de l’intervention a été élevé et présentait un excellent profil d’innocuité. Des études ultérieures portant sur la comparaison des voies transradiale et transfémorale pourraient être utiles pour contribuer à populariser le recours à la voie transradiale dans les BEM-VG.

Section snippets

Methods

Patients who underwent LV-EMB via radial arterial access from 3 centres (Canada, Germany, and Japan) were retrospectively evaluated. All procedures were performed by experienced operators who perform most of their coronary interventions via radial access. Patients who had attempted transradial LV-EMBs but then necessitated conversion to transfemoral access were also included.

Population and preprocedural characteristics

A total of 102 patients who underwent transradial LV-EMB were identified. The median age was 57 (48–68) years, and approximately half (57%) of the patients were male. The median LVEF was 35% (25%–44%). For all but 1 patient, it was their first LV-EMB procedure, with dilated cardiomyopathy (43%), infiltrative cardiomyopathy (25%) or myocarditis (20%) making up the primary indications for LV-EMB. The demographics of the patients are detailed in Table 1.

Access, sheath and guide catheters

All patients but 1 underwent right radial

Discussion

This article reports a case series of transradial LV-EMB that was associated with a high rate of success, coupled with an extremely low rate of complications. Transradial LV-EMB has been previously reported in isolated case reports and small single-centre experiences.10, 11, 12, 14 The strength of the current study lies in its multicentre and international nature including more than 100 patients. The current series lends further weight to the feasibility and safety of transradial LV-EMB despite

Conclusions

In this case series, the transradial route appears to be a safe and highly effective way to perform LV-EMB. Whether transradial LV-EMB is safer and more effective than transfemoral LV-EMB can only be determined by head-to-head comparisons or a much larger observational data. Given the positive experience of transradial coronary interventions over transfemoral interventions that includes essentially eliminating life-threatening access-site complications and the widespread adoption of radial

Disclosures

The authors have no conflicts of interest to disclose.

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Cited by (7)

Transradial left ventricular endomyocardial biopsy feasibility, safety and clinical usefulness: Initial experience of a tertiary university center
2020, Revista Portuguesa de Cardiologia
Citation Excerpt :
Indeed, in the setting of myocarditis, the largest published series reports a 92.1% vs. 81.3% diagnostic yield,4 and in the setting of predominant LV disease, the difference is quite large and the LV approach is favored with 97.8% vs. 53%, respectively.3 Published data from the transradial approach do not allow for a comparison of left versus right approaches, however the conclusions are similar to ours: the results added to the clinical dilemma, confirming, excluding or clarifying a diagnostic hypothesis.13 Despite its advantages, the transradial LV endomyocardial biopsy technique is not without limitations.
Over the last decade, several studies have suggested that left ventricular endomyocardial biopsy is safer and has a higher diagnostic yield than transvenous right ventricular biopsy. In addition, recent publications indicate that the transradial approach is a feasible and safe alternative to the transfemoral approach for sampling the left ventricle. We report our initial experience with transradial endomyocardial biopsy with regards to feasibility, safety and usefulness.
Single-center registry of consecutive patients undergoing intended transradial left endomyocardial biopsy. Clinical and technical data were collected prospectively, with a particular focus on success rate and complications.
Twenty-seven patients were screened for left ventricle biopsy. Twenty (25) were selected for an intended transradial approach (mean age 51±18 years old, 22 male). Success rate was 100% with no crossover to femoral approach. There were no major complications. Two patients experienced mild radial spasm. One of them also had a run of non-sustained ventricular tachycardia.
Indication for biopsy was either myocarditis or cardiomyopathy of unknown etiology. The final diagnosis was acute lymphocytic myocarditis in five patients, chronic myocarditis in one patient, amyloid light-chain amyloidosis in four patients and transthyretin amyloidosis in six patients. Myocarditis was ruled out in eight patients and amyloidosis in one patient.
Transradial left ventricle endomyocardial biopsy is a very safe and feasible method of sampling the myocardium for histopathological analysis, with a good diagnostic yield and clinically meaningful results in properly selected patients.
Durante a última década, vários estudos têm sugerido que a biópsia endomiocárdica ventricular esquerda é mais segura e de superior rentabilidade diagnóstica do que a do ventrículo direito. Adicionalmente, várias publicações recentes têm introduzido a abordagem transradial como uma alternativa exequível e segura à transfemoral, para amostrar o ventrículo esquerdo. O objetivo deste estudo é reportar a experiência inicial de um centro em biópsia endomiocárdica ventricular esquerda transradial, relativamente a exequibilidade, segurança e utilidade.
Registo unicêntrico de doentes consecutivos submetidos a biópsia endomiocárdica ventricular esquerda, com acesso de primeira intenção radial. Registaram-se os dados clínicos e técnicos, com particular foco na taxa de sucesso e complicações.
Foram submetidos a biópsia endomiocárdica ventricular esquerda 27 doentes, 25 dos quais pré-selecionados para acesso transradial (idade média 51±18, 22 homens). A taxa de sucesso foi de 100%. Não ocorreram complicações major, apenas espasmo radial em dois doentes, num dos quais se observou uma salva de taquicardia ventricular não mantida. A indicação foi miocardite ou miocardiopatia de etiologia a esclarecer. O diagnóstico final foi de miocardite aguda em cinco doentes, miocardite crónica em um doente, amiloidose AL em quatro doentes e ATTR em seis doentes. Excluiu-se miocardite em oito doentes e amiloidose em um doente.
A biópsia endomiocárdica ventricular esquerda transradial demonstrou ser segura, exequível e de boa rentabilidade diagnóstica, com resultados clinicamente relevantes em doentes selecionados.
Radial versus femoral approach for saphenous vein grafts angiography and interventions
2019, American Heart Journal
Coronary angiography and intervention to saphenous venous grafts (SVGs) remain challenging. This study aimed to investigate the feasibility and safety of the radial approach compared to femoral access in a large cohort of patients undergoing SVG angiography and intervention.
Data from 1,481 patients from Canada, United States, and Spain who underwent procedures between 2010 and 2016 were collected. Patients must have undergone SVG coronary angiography and/or intervention. Demographics, procedural data, and in-hospital complications were recorded.
Procedures were undertaken by either the radial (n = 863, 211 intervention) or femoral (n = 618, 260 intervention) approach. The mean number of SVGs per patient was similar between groups (radial 2.3 ± 0.7 vs femoral 2.6 ± 1.1, P = .61), but the radial group required a fewer number of catheters (2.6 ± 1.7 vs 4.1 ± 1.1, P < .001). Fluoroscopy time was comparable between groups, and there was a trend toward lower contrast volume in the radial group (P = .045). Overall, the total dose of heparin was significantly higher in the radial group (P < .001); however, radial patients experienced significantly less access-site bleeding complications (P < .001). Outpatients undergoing radial SVG interventions had a higher likelihood of a same-day discharge home (P < .001).
Radial access for SVG angiography and intervention is safe and feasible, without increasing fluoroscopy time. In experienced centers, radial access was associated with fewer catheters used, lower contrast volume, and lower rate of vascular access-site bleeding complications. Moreover, outpatients undergoing SVG percutaneous coronary intervention though the radial approach had a higher likelihood of a same-day discharge home.
The Right Way to the Left Ventricle: A Better Approach to Endomyocardial Biopsy?
2018, Canadian Journal of Cardiology
Is this the prime time for transradial access left ventricular endomyocardial biopsy?
2021, Interventional Cardiology: Reviews, Research, Resources
The safety and feasibility of transitioning from transfemoral to transradial access left ventricular endomyocardial biopsy
2020, Journal of Invasive Cardiology
Radial versus femoral approach for left ventricular endomyocardial biopsy
2019, EuroIntervention

View all citing articles on Scopus

: See editorial by Giraldeau, pages 1247–1249 of this issue.

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Clinical ResearchTransradial Approach for Left Ventricular Endomyocardial Biopsy

Abstract

Background

Methods

Results

Conclusions

Résumé

Contexte

Méthodologie

Résultats

Conclusion

Section snippets

Methods

Population and preprocedural characteristics

Access, sheath and guide catheters

Discussion

Conclusions

Disclosures

Am J Cardiol

Lancet

Lancet

Am J Cardiol

Int J Cardiol

Am Heart J

Am J Cardiol

Contribution and risks of left ventricular endomyocardial biopsy in patients with cardiomyopathies: a retrospective study over a 28-year period

Circulation

Comparative evaluation of left and right ventricular endomyocardial biopsy: differences in complication rate and diagnostic performance

Circulation

Clinical Research
Transradial Approach for Left Ventricular Endomyocardial Biopsy