Endomyocardial biopsies in pediatric patients with no irradiation. Use of internal jugular venous approach and echocardiographic guidance.

Heart transplants in pediatric patients have moved from an experimental, end-stage treatment to a valuable therapy for inoperable congenital heart disease and dilated cardiomyopathies. Cardiac rejection is a frequent problem in children with heart transplants. The technical difficulties of obtaining biopsies in small children have encouraged the use of noninvasive methods of detection although endomyocardial biopsy continues to be the most reliable method of surveillance for cardiac rejection. We examined our experience over 7 years with 4 patients (ages 8 months to 10 years) who had a total of 88 endomyocardial biopsies using echocardiographic guidance. The biopsies were done using a Caves-Schultz biotome via the right internal jugular vein. Biopsies were performed in the procedure room, 61%; pediatric intensive care unit, 18%; hospital private room, 18%; and catheterization laboratory, 3% of the time. At 5.0, 6.5, or 8.5 French biotome was used depending on the size of the patient. Twelve episodes of rejection were detected in these patients. The time for venous access was 17 +/- 15 min, and the biopsies took 25 +/- 11 min using this approach. Biopsies were obtained from the right ventricular free wall, apex, and septum to detect focal rejection for a total of 4-6 tissue samples per biopsy. Neither general anesthesia nor fluoroscopy was needed for these biopsies. Costs ranged from $1120 in the patient room to $1590 in the pediatric intensive care unit. Five different biopsies using a femoral approach with fluoroscopic guidance averaged $2250 and did not include the functional assessment obtained using echocardiography. Using the echocardiogram one can see the ventricular muscle and completely avoid perforation. Thus, this technique is technically feasible in children with few complications at a reduced cost, compared to fluoroscopically guided biopsies.