We eagerly awaited the publication of an updated expert consensus on endomyocardial biopsy (EMB), which has been lacking for the past 14 years.¹ In fact, notwithstanding the tremendous progresses made in the field of non-invasive cardiovascular imaging during this time window, EMB still provides fundamental diagnostic and prognostic information while also being an important research tool, and an updated scientific document on EMB was highly needed. Although Seferović et al.² provide a contemporary and comprehensive perspective on the topic, we fear that some points may have not been adequately addressed in their statement.

First, concerning the access site to left ventricular EMB, we and others prefer using a transseptal approach with a steerable sheath as compared to a retrograde approach through the aortic valve.³ In fact, the transseptal approach facilitates the access to septal and inferior-lateral myocardial segments, which are commonly involved in arrhythmogenic cardiomyopathies, while also allowing for stable catheter positioning when catheter ablation is performed during the same procedure. For these reasons, we believe that the transseptal approach should be preferred for electroanatomical voltage mapping (EVM)-guided left ventricular EMB, and that Figure 4 should incorporate such an approach instead of the retrograde access to the left ventricle through the aortic valve.

Second, we feel that the use of EVM as a guide for EMB is not adequately stressed throughout the document. In fact, EVM has the potential to enhance diagnostic accuracy of EMB, by allowing sampling myocardial segments involved by patchy disease processes (e.g. myocarditis, sarcoidosis). Our group recently showed that EVM has comparable sensitivity to cardiac magnetic resonance imaging in predicting EMB results, with superior specificity, and that combining both techniques yields optimal sensitivity (95%).³ Furthermore, we previously reported that unipolar EVM, although underutilized, carries higher sensitivity than bipolar EVM in guiding EMB among patients with non-ischaemic cardiomyopathies, because of its wider field of view, which allows the detection of intramural and/or subepicardial pathological substrates.^{3, 4} We believe that this information may be of practical help for physicians, and should be incorporated in an updated consensus statement.

Once considered a risky and invasive diagnostic tool in the hands of the heart failure/transplant specialist, EMB has tremendously evolved over the past 15 years to become a precious asset for the electrophysiologist. The importance of a precise differential diagnosis among the different disease processes once grouped under the umbrella of non-ischaemic cardiomyopathy cannot be overemphasized in the era of precision medicine,⁵ and a more widespread performance of EMB by electrophysiologists could turn the electrophysiology procedure into a one-stop shop for diagnosis (through EVM and EMB) and treatment (through catheter ablation) for non-ischaemic cardiomyopathy patients with an arrhythmic presentation.

我们热切地等待着关于心内膜心肌活检 (EMB) 的最新专家共识的发布，这是过去 14 年来一直缺乏的。¹事实上，尽管在此时间窗口内无创心血管成像领域取得了巨大进展，但 EMB 仍然提供基本的诊断和预后信息，同时也是一种重要的研究工具，并且迫切需要一份关于 EMB 的最新科学文件。虽然 Seferović等人。²提供有关该主题的当代和全面的观点，我们担心他们的陈述中可能没有充分解决某些问题。

首先，关于左心室 EMB 的进入部位，与通过主动脉瓣的逆行方法相比，我们和其他人更喜欢使用带有可操纵鞘的经间隔方法。³事实上，经室间隔入路有助于进入室间隔和下外侧心肌节段，这些节段通常与致心律失常性心肌病有关，同时在同一手术中进行导管消融时，还可以实现稳定的导管定位。由于这些原因，我们认为对于电解剖电压映射 (EVM) 引导的左心室 EMB，应该首选经间隔方法，并且图 4应该采用这种方法，而不是通过主动脉瓣逆行进入左心室。

其次，我们认为在整个文档中没有充分强调使用 EVM 作为 EMB 的指南。事实上，EVM 具有提高 EMB 诊断准确性的潜力，因为它允许对涉及斑片状疾病过程（例如心肌炎、结节病）的心肌节段进行采样。我们小组最近表明，EVM 在预测 EMB 结果方面与心脏磁共振成像具有相当的敏感性，具有卓越的特异性，并且结合这两种技术产生最佳敏感性 (95%)。³此外，我们之前报道过，单极 EVM 尽管未被充分利用，但在指导非缺血性心肌病患者的 EMB 方面比双极 EVM 具有更高的灵敏度，因为它的视野更广，可以检测壁内和/或心外膜下的病理基质。^{3, 4}我们相信这些信息可能对医生有实际帮助，应纳入更新的共识声明中。

EMB 曾经被认为是心力衰竭/移植专家手中的危险和侵入性诊断工具，在过去的 15 年中发生了巨大的变化，成为电生理学家的宝贵资产。在精准医学时代，对曾经归类为非缺血性心肌病的不同疾病过程进行精确鉴别诊断的重要性怎么强调都不为过，⁵电生理学家更广泛地开展 EMB 可以将电生理学程序转变为一种- 为有心律失常表现的非缺血性心肌病患者提供诊断（通过 EVM 和 EMB）和治疗（通过导管消融）的一站式服务。