Feasibility of Using a Sheathless Guiding Catheter for Left Ventricular Endomyocardial Biopsy Performed by Transradial Approach

Abstract: The role of endomyocardial biopsy (EMB) in the diagnosis and treatment of adults presenting a newly unexplained cardiomyopathy remains controversial and the clinical indication varies among different centers. Furthermore, the choice of the ventricular site for EMB is still under debate. The right ventricular EMB is commonly used due to safety features and left ventricle (LV) EMB has not yet gained acceptance because of concerns about possible complications. Of note, when LV-EMB is performed, the femoral artery is usually the access site. There is a large body of evidence supporting the safety and feasibility of transradial approach in a broad spectrum of patients and settings in the catheterization laboratory. Therefore, the aim of the present manuscript is to report the feasibility of performing a LV-EMB by the transradial approach using a sheathless guiding catheter as an ad hoc procedure. 

J INVASIVE CARDIOL 2014;26(12):E161-E163

Key words: endomyocardial biopsy, transradial approach, sheathless guiding catheter

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The role of endomyocardial biopsy (EMB) in the diagnosis and treatment of adults presenting a newly unexplained cardiomyopathy remains controversial and the clinical indication varies among different centers.¹ Moreover, due to the fact that there are no data based on randomized, controlled treatment on the utility of EMB, the current recommendations are based on case-control series and expert opinions.¹ Furthermore, the choice of the ventricular site for EMB is still under debate. However, although right ventricular EMB approached by right internal jugular vein or femoral vein is commonly used due to safety features, left ventricle (LV)-EMB has not yet gained acceptance because of concerns about possible complications.² Of note, when LV-EMB is performed, the femoral artery is usually the access site.^1-4 It is well known, however, that there is a large body of evidence supporting the safety and feasibility of transradial approach in a broad spectrum of patients and settings in the catheterization laboratory.^5,6 Therefore, the aim of the present manuscript is to report the feasibility of performing a LV-EMB by the transradial approach using a sheathless guiding catheter as an ad hoc procedure. 

Case Report

A 55-year-old woman was admitted with congestive heart failure. On admission, a Doppler echocardiography showed severe LV hypertrophy, with LV ejection fraction (LVEF) of 55% and severe diastolic dysfunction exhibiting a restrictive filling pattern and mild-to-moderate pericardial effusion. The patient was initially stabilized with medical treatment and in an attempt to diagnose the etiology of this cardiomyopathy, she underwent coronary angiography and EMB. Of note, the patient’s weight was 32.7 kg (72 lbs) and 1.52 m tall with a very small radial artery pulse (Figure 1A). As part of our institutional protocol, coronary angiography was performed by transradial approach using 5 Fr catheters (Figure 1B) and showed angiographically normal coronary arteries. At this point, the challenge was to perform an LV-EMB by transradial approach. We then selected a 7.5 Fr Judkins right 4 sheathless guiding catheter (SheathLess Eaucath; Asahi-Intecc, Co) to guide a 5.5 Fr bioptome (Cordis Corporation) into the LV (Figures 1C and 1D). After retrieval of the 5 Fr introducer sheath, the sheathless guiding catheter was advanced (Figure 2A) up to the ascending aorta over a J-shaped 0.035˝ guidewire, the dilator was retrieved, and the catheter was directed over the wire toward the mid-to-distal LV cavity under fluoroscopic guidance (Figure 2B). The bioptome was then advanced through the sheathless guiding catheter and 5 samples were obtained under fluoroscopic guidance (Figure 2C and Video 1). The guiding catheter was removed over the wire, which was left in the radial artery, and the 5 Fr introducer sheath was again inserted. Hemostasis was obtained using a Bengal radial compressor band (Benrikal Services, Inc) with a plethysmography-guided patent hemostasis technique after sheath removal. Preemptive heparin was not used; rather, we used a provisional strategy (in which heparin is only administered if radial patency is not achieved).⁷ Since radial flow remained during hemostasis (patent hemostasis technique),⁸ no heparin was used in this case. The postprocedural course was uneventful and the patient was discharged home and followed in the heart failure clinic. Histologic analysis subsequently revealed a case of an infiltrative cardiomyopathy such as amyloidosis.

Discussion

While a prior report has described the use of forearm veins for right ventricular EMB,⁹ the present report demonstrates that LV-EMB can also be accomplished using the radial artery and radial-specific sheathless equipment. It has been suggested that LV-EMB might be preferred given the fact that LV-EMB affords a higher diagnostic yield as compared to right ventricle EMB, while enabling a lower rate for complications.² In addition, the transradial approach affords an effective strategy to reduce procedure-related bleeding complications.^5,6

The SheathLess Eaucath guiding catheter is designed to minimize the radial puncture at the access site, while providing a larger inner lumen for interventional procedures. In the present case, the 7.5 Fr catheter has an outer diameter of 2.49 mm, which is smaller than the outer diameter of a conventional 6 Fr introducer sheath (2.62 mm), and thus slightly bigger than the originally placed 5 Fr introducer sheath (2.29 mm) through which coronary angiogram was performed. This strategy therefore permitted an easy advancement of the 5.5 Fr bioptome. Finally, since the patent hemostasis strategy significantly reduces the incidence of radial artery occlusion,⁸ we have incorporated this technique in our everyday institutional practice, and was successfully used in the present case.

Conclusion

The present report shows the feasibility of using a sheathless catheter to guide access for LV-EMB, providing one step further for the transradial interventional cardiologist, and suggesting that this approach may be considered when LV-EMB is chosen.

Acknowledgment. The authors wish to thank the nurses and x-ray technicians of the catheterization laboratory of the Hôtel-Dieu de Québec, for their daily support with clinical research.

References

1. Cooper LT, Baughman KL, Feldman AM, et al; American Heart Association; American College of Cardiology; European Society of Cardiology; Heart Failure Society of America; Heart Failure Association of the European Society of Cardiology. The role of endomyocardial biopsy in the management of cardiovascular 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. J Am Coll Cardiol. 2007;50(19):1914-1931. 
2. Yilmaz A, Kindermann I, Kindermann M, et al. Comparative evaluation of left and right ventricular endomyocardial biopsy: differences in complication rate and diagnostic performance. Circulation. 2010;122(9):900-909.
3. Brooksby IA, Jenkins BS, Coltart DJ, Webb-Peploe MM, Davies MJ. Left-ventricular endomyocardial biopsy. Lancet. 1974;2(7891):1222-1225.
4. Rios B, Nihill MR, Mullins CE. Left ventricular endomyocardial biopsy in children with the transseptal long sheath technique. Cathet Cardiovasc Diagn. 1984;10(4):417-423.
5. Bertrand OF, Rao SV, Pancholy S, et al. Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey. JACC Cardiovasc Interv. 2010;3(10):1022-1031.
6. Caputo RP, Tremmel JA, Rao S, et al. Transradial arterial access for coronary and peripheral procedures: executive summary by the transradial committee of the SCAI. Catheter Cardiovasc Interv. 2011;78(6):823-839.
7. Pancholy SB, Bertrand OF, Patel T. Comparison of a priori versus provisional heparin therapy on radial artery occlusion after transradial coronary angiography and patent hemostasis (from the PHARAOH study). Am J Cardiol. 2012;110(2):173-176. 
8. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008;72(3):335-340.
9. Moyer CD, Gilchrist IC. Transradial bilateral-cardiac catheterization with endomyocardial biopsy: a feasibility study. Catheter Cardiovasc Interv. 2005;64(2):134-137.

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From the ¹Quebec University Hospital Centre, Laval University, Quebec City, Canada; ²Quebec Heart & Lung Institute, Laval University, Quebec City, Canada; and ³Penn State’s Hershey Medical Center, Heart & Vascular Institute, Pennsylvania State University, Hershey, Pennsylvania.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted February 26, 2014, provisional acceptance given March 18, 2014, final version accepted May 2, 2014.

Address for correspondence: Rodrigo Bagur, MD, PhD, FAHA, Division of Cardiology, Department of Medicine, Quebec University Hospital Centre, Assistant Clinical Professor, Department of Medicine, Laval University, 11 côte du Palais, L’Hotel-Dieu de Québec - G1R 2J6 - Quebec City, Quebec, Canada. Email: rodrigo.bagur@fmed.ulaval.ca or rodrigobagur@yahoo.com