Heart Biopsy for Cardiovascular Pathology Diagnosis
The stories are haunting: a young, seemingly healthy athlete collapses on the playing field and dies; a child died on the basketball court; a young woman collapses while running track. According to Joseph Maleszewski, M.D., Supervisor of Cardiovascular Pathology at the Mayo Clinic in Rochester, Minnesota, these deaths are not uncommon at all and also sadly familiar.
In the cover story of the May issue of CAP TODAY, Dr. Maleszewksi discusses the complexities of cardiovascular pathology cases, especially for young athletes. “A patient comes in, and they tell us, ‘I had a brother or sister die suddenly and young,’ and the pathologist who performed the autopsy suspected a cardiomyopathy or a heritable arrhythmia syndrome. Maybe a parent has died. Or perhaps—most tragically—a parent comes in and says, ‘I’ve had a child die suddenly.’”
The questions hang in the air. Will the same thing happen to me? To my other children?
“One of the nagging issues pathologists are dealing with is the nonuniformity in our approach to cardiac dissection and evaluation,” said Dr. Maleszewski. Particularly in the postmortem setting, he says, it’s less acceptable to obtain an expert’s opinion for cardiovascular disease, the way it is often done with neuropathology. One reason is cost. “And perhaps there’s not a good understanding of how important it is for these family members to understand the heritable implications in these cases,” he added.
According to the article, patients with cardiomyopathies, myocarditis, amyloidosis, genetic conditions, etc., don’t always get a correct diagnosis, and, by extension, may not get the right treatment. Therefore, it’s important to look and accurately identify the diagnosis.
The article discusses the use of endomyocardial biopsy. The role of endomyocardial biopsy is divided into post-transplant and nontransplant settings. Post-transplant, endomyocardial biopsy is widely used in monitoring heart patients. In the nontransplant setting, the common clinical setting for endomyocardial biopsy is acute heart failure. Biopsy can help identify inflammation of the heart muscle and, if present, whether it’s viral or some other infectious-type myocarditis, or if it’s noninfectious.
For pathologists, concerns about performing endomyocardial biopsy include whether they’re prepared to handle specimens.
According to Dr. Maleszewski, ideally, cardiologists would give the pathologist a heads-up before doing an endomyocardial biopsy, giving the pathologist ample time to make sure the cath lab has the appropriate media to fix the specimen, or even to reach out to a larger center with subspecialty knowledge for guidance. “Having all those pieces in place, and knowing the plan upfront, is infinitely better than the pathologists hearing, ‘Hey, we just did this biopsy—now what do we do?’ What we’re trying to avoid is finding out the questions after everything’s been processed.”
Another challenge is the processing time. Since some clinical situations are dire, pathologists might need to turn specimens around quickly. “To do so, we really need a good understanding of what the clinical question is upfront,” says Dr. Maleszewski, “so we can order all the ancillary studies we’ll need right at the outset.”
Further, communication is key. “I strongly encourage very tight working relationships between pathologists and clinical colleagues,” says Dr. Maleszewski. At Mayo, he says, “I couldn’t do my job if I wasn’t on the phone with my clinicians every day. I don’t want to feel like I’m going to be blindsided at any moment.”
Dr. Maleszewski knows he’s seeking this in a time of constrained resources. “But in the long run, such interactions are time saving and cost saving in their own right.” Even in the busiest of practices, he says, “some steps are reasonable and can be taken, like having a well-designed requisition that alerts the person to the relevant issues upfront. And it would pay dividends right away.”
Read the full article for more information.
Leslie Cooper, M.D., Chair of the Department of Cardiology and Professor of Medicine, Mayo Clinic, Jacksonville, Florida; Stephen Cohle, M.D., Cardiovascular Pathologist with Michigan Pathology Specialists, which is affiliated with Spectrum Health, Grand Rapids, Mich.; and Heinz-Peter Schultheiss, M.D., Professor for Internal Medicine, Cardiology, and Intensive Care, and Chief of Cardiology, Charité-Universitätsmedizin Berlin, also provided input for the article.