Elsevier

Mayo Clinic Proceedings

Volume 64, Issue 10, October 1989, Pages 1235-1245
Mayo Clinic Proceedings

Evaluation of Postmortem Endomyocardial Biopsy Specimens From 38 Patients With Lymphocytic Myocarditis: Implications for Role of Sampling Error

https://doi.org/10.1016/S0025-6196(12)61286-5Get rights and content

Among 38 hearts from autopsies in which lymphocytic myocarditis contributed to death, 10 endomyocardial specimens from the apical septal aspect of each ventricle (760 specimens) and 6 slices of ventricular myocardium (228 slices) were evaluated for myocarditis by the Dallas criteria. For each case, the number of positive biopsy samples correlated well with the mean lymphocyte counts in biopsy tissues (P<0.0001) and the mean number of inflammatory foci per square centimeter in myocardial slices (P<0.001). Right ventricular biopsy specimens, however, were positive in only 63% of the 38 cases and 17% of the 380 specimens. Similarly, left ventricular biopsy tissues were positive in only 55% of the cases and 20% of the specimens. Sampling error was somewhat more prevalent among the 11 cases with isolated myocarditis than in the 27 with myocarditis and other illnesses. Even when 10 biopsy specimens per ventricle were evaluated, the frequency of false-negative results was 45% for the left and 37% for the right ventricle. Although myocarditis was noted in 68% of the 38 septal slices, it involved the subendocardium of the right ventricle (from which biopsy specimens are usually obtained) in only 24%. Because of the mild and focal nature of the inflammatory infiltrates and involvement of regions inaccessible to the bioptome, sampling error contributes appreciably to false-negative results in endomyocardial biopsy tissue from patients with myocarditis. Thus, when myocarditis is evaluated by biopsy alone, only positive findings are considered diagnostic.

Section snippets

Study Groups.

From the autopsy records at the Mayo Clinic for the 15 years between 1973 and 1987, 201 cases were identified in which myocarditis had been recorded as the sole or a contributory cause of death. Among these, 38 met the following criteria and were considered suitable for the current study: (1) the Dallas criteria6 were fulfilled for the diagnosis of myocarditis (Fig. 1), (2) the inflammatory infiltrate was predominantly lymphocytic, and (3) the gross cardiac specimen was available for review and

Study Groups.

For groups I and II, the ranges in age were similar (3 months to 86 years and 5 to 92 years, respectively), but the mean ages differed appreciably (35 and 51 years, respectively). Myocarditis affected male patients twice as frequently as female patients—7 (64%) in group I and 18 (67%) in group II were males.

Sudden death occurred in 91% of group I but in only 41% of group II. In group II, it occurred most frequently among patients with those disorders commonly known to be associated with sudden

DISCUSSION

In light of the results of the current investigation of the evaluation of myocarditis by endomyocardial biopsy, three areas warrant further comment: (1) the extent of sampling error, (2) the role of quantitation of inflammatory cells, and (3) the limitations of the current study.

ACKNOWLEDGMENT

We thank Duane M. Ilstrup, M.S., Section of Biostatistics, for assistance with the statistical analysis of the data.

REFERENCES (15)

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    Citation Excerpt :

    Other limitations of the Dallas criteria include significant interobserver variability and sampling errors [66,67]. Although less of an issue in autopsy-derived tissue, the focal nature of the disease leads to sampling errors that have been shown to compromise the sensitivity of the histopathological diagnosis of myocarditis by EMB [68,69]. Chow et al. had estimated that a mean of 17 samples per patient would be required to establish a diagnosis of myocarditis [69], which likely explains why examining an increased number of cardiac tissue blocks at the time of autopsy resulted in a greater likelihood of identifying focal myocarditis.

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Presented in part at the International Symposium on Inflammatory Heart Disease, Snowmass, Colorado, July 28, 1988.

*

Current address: Loma Linda University Medical Center, Loma Linda, California.

Current address: Baylor College of Medicine, Houston, Texas.

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