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Recommendation Table 6 — Recommendations for endomyocardial biopsy (see Evidence Table 6)

Recommendations Classa Levelb EMBc is recommended in patients with high-risk myocarditisd, and/or haemodynamic instability, and/or in patients with intermediate-risk myocarditis not responding to conventional therapy in order to detect a specific histologic subtype and to assess the presence of viral genome for treatment.34,63,73,131 I C © ESC 2025

EMB, endomyocardial biopsy. aClass of recommendation. bLevel of evidence. cContemporary evaluation of EMB should be based on histology, immunohistology, and molecular pathology for detection of viral infections in myocardial and blood samples (see also Table 11). dSee Table 7.

  

  

  

 

  


  


	 


 

 

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Figure 15 Histopathological findings in myocarditis. HE, haematoxylin eosin. (A–C) Endomyocardial biopsy for acute lymphocytic myocarditis reveals cardiomyocyte necrosis (A, HE stain) and severe focal infiltration of CD3+ T cells (B) and CD68+ macrophages (C), as detected by immunohistochemistry. (D–F) In chronic lymphocytic myocarditis, no cardiomyocyte injury is observed, but there is focal replacement fibrosis (D, HE) in the presence of CD3+ T cells (E) and CD68+ macrophages (F). (G–I) In acute eosinophilic myocarditis, necrosis of cardiomyocytes is associated with numerous eosinophilic granulocytes (G, Giemsa stain), some CD3+ T cells (H), and numerous CD68+ macrophages (I). (J–L) Areas with severe cardiomyocyte necrosis in the presence of extensive focal and diffuse infiltration of eosinophilic granulocytes (J, Giemsa stain), CD3+ T cells (K), and CD68+ macrophages and CD68+ giant cells (L) are typical of giant-cell myocarditis. (M–O) Cardiac sarcoidosis is histologically characterized by the presence of granulomas, usually in the absence of cardiomyocyte necrosis (M, Giemsa stain), but with focal infiltration of CD3+ T cells (N) and numerous CD68+ macrophages and CD68+ giant cells (O).

ESC Guidelines                                                                                                                                                                                          3985

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