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Echo-controlled endomyocardial biopsy in orthotopic heart transplantation with bicaval anastomosis
A M Grande1, G Minzioni, L Martinelli
1Divisione Cardiochirurgia, IRCCS Policlinico San Matteo, Università degli Studi di Pavia.
Insights
Bicaval heart transplantation with echocardiographic-guided endomyocardial biopsies (EMB) offers safety benefits. This technique maintains right atrial anatomy and reduces complications compared to fluoroscopy, though fluoroscopic backup is advised.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Imaging
Background:
- Bicaval heart transplantation preserves right atrial anatomy by anastomosing venae cavae.
- Endomyocardial biopsy (EMB) is crucial for monitoring heart transplant recipients.
- Echocardiographic guidance for EMB is an evolving technique.
Purpose of the Study:
- To evaluate the safety and efficacy of echocardiographic guidance during endomyocardial biopsies in patients undergoing bicaval heart transplantation.
- To compare complications associated with echocardiographic versus fluoroscopic guidance for EMB.
Main Methods:
- A cohort of 38 patients receiving bicaval heart transplantation underwent 339 endomyocardial biopsies (EMB).
- EMB was performed under echocardiographic control (309 cases) or fluoroscopy (30 cases).
- Complications related to EMB procedures were meticulously recorded and analyzed.
Main Results:
- Echocardiographic guidance for EMB resulted in one major complication (right hemothorax requiring surgery).
- Fluoroscopic-guided EMB was associated with other complications, including left hemothorax and pneumothorax.
- Echocardiographic guidance facilitated better biopsy site selection and immediate cardiac performance monitoring.
Conclusions:
- Echocardiographic guidance for EMB in bicaval heart transplantation is associated with a lower risk of major complications and reduced radiation exposure.
- This technique enhances procedural safety by improving biopsy site selection and allowing real-time monitoring.
- Fluoroscopic guidance should be readily available as a backup, especially in the early postoperative period when suture lines may be difficult to navigate.
Abstract:
Starting in January 1995, we performed heart transplantation, randomly using standard and bicaval techniques. In the latter technique, the anatomy of the right atrium is maintained, since the venae cavae are anastomosed. In 38 patients who received heart transplantation with bicaval anastomosis, 339 endomyocardial biopsies (EMB) were performed. EMB was done under echocardiographic control in 309 cases, whereas the remaining 30 were done under fluoroscopy. When EMB was echo-guided there was one major complication, namely right hemothorax in a 29-year-old man, who had had heart transplantation one week before, and this required surgical exploration. Other complications, correlated to venipuncture were: left hemothorax in a 65-year-old woman determined by arterial puncture, treated by means of chest tube drainage; pneumothorax (1 case). Echocardiographic guidance during EMB allows a better choice of biopsy site, reduces the risk of damaging cardiac structures and allows immediate monitoring of heart performance. Moreover the risk of X-ray exposure to both patient and operators is reduced. In any case, because the superior vena cava suture line is not visualized by two-dimensional echocardiography, if the bioptome cannot be introduced easily through superior vena cava, fluoroscopic control should be immediately applied, particularly in the early post-operative period when cicatrization is not complete.