Electro-Anatomically-Guided Endomyocardial Biopsy in a Patient With Focal Myocardial Infiltration and Chronic Lymphocytic Leukemia

A 53-year-old female was admitted to the cardiology department on account of signs and symptoms of congestive heart failure (HF) with severe peripheral edema and dyspnea on exertion (New York Heart Association class III) for the past 3 months. Her recent past medical history revealed diagnosis of chronic lymphocytic leukemia (CLL) on chlorambucil treatment. Initial laboratory tests revealed slightly elevated N-terminal-pro-B-type natriuretic peptide of 157 pg/mL, hyperleukocytosis (22.2 x 1000/µL; 72% lymphocytes), normal troponin, C-reactive protein concentration, and polyclonal immunofixation pattern. Transthoracic echocardiography showed preserved left ventricular systolic function with the presence of akinesia in the basal segment of the inferior and posterior wall, pericardial fluid layer of 14 mm, asymmetrical left ventricular hypertrophy (septal wall thickness 18 mm), normal atrial size, and hyperechogenic intra-wall left ventricular band (Figure, A [arrow]).

Cardiac magnetic resonance imaging showed intramural late gadolinium enhancement and edema within the inferior-septal and inferior wall of the left ventricle (LV), suggestive of infiltration in the course of leukemia (Figure, B [arrow]). Given the suspicion of CLL infiltration, we performed a guided LV biopsy. Following administration of 5000 IU of unfractionated heparin via intravenous bolus, a transaortic 3D electro-anatomical voltage mapping was performed via the left common femoral artery (8 French [Fr]). The procedure was performed with an Advisor HD Grid mapping electrode with EnSite X system (Abbott), which denoted a low-voltage area within posterior-basal and inferior-basal segments of LV (Figure, C). The mapping electrode was left in this area as a landmark and subsequently a 6-Fr endomyocardial bioptome via 8-Fr multipurpose guiding catheter was introduced via the left common femoral artery (8 Fr); 7 myocardial specimens were acquired from the low-voltage zone (Figure, D; red arrow: mapping electrode; yellow arrow: bioptome). The arterial access sites were successfully sealed using an 8-Fr Angio-Seal device (Terumo).

Immunohistological staining of the endomyocardial biopsy samples showed active myocarditis with evidence of mixed fibrosis in Masson trichrome stain, lack of typical leukemic infiltrates, and negative Congo stain (Figure, E; red: CD68 (+) macrophages adhered to injured cardiomyocytes). The procedure confirmed that there was no sign of CLL involvement in the myocardium, and we proceeded with chlorambucil treatment. In addition, the patient received a complex HF pharmacotherapy including high dose loop diuretic, spironolactone, sacubitril-valsartan, dapagliflozin, and beta-blocker, leading to significant and persistent clinical improvement.

The present clinical scenario demonstrates the utilization of an electro-anatomical mapping electrode as a useful landmark for the precision endomyocardial biopsy targeted at the low-voltage zone. Although the concept of a guided biopsy is not new, previous applications used techniques allowing for visualization of the bioptome in an electro-anatomical system.1 The present case serves as an example that the mere mapping electrode, given its shape and stability, may serve as a reliable indicator of the acquired low-voltage zone for the purpose of guided endomyocardial biopsy.

Affiliations and Disclosures

From the ¹First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; ²Upper-Silesian Medical Center, Katowice, Poland; ³Member of the European Reference Network on Heart Diseases - ERN GUARD-HEART; ⁴Department of Histology and Cell Pathology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Maciej T. Wybraniec, MD, PhD, First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 47 Ziołowa St. 40-635 Katowice, Poland. E-mail: maciejwybraniec@gmail.com

Reference:

1. Casella M, Dello Russo A, Bergonti M, et al. Diagnostic yield of electroanatomic voltage mapping in guiding endomyocardial biopsies. Circulation. 2020;142(13):1249-1260. doi: 10.1161/CIRCULATIONAHA.120.046900