The technique of endomyocardial biopsy (EMB) has been refined over the last 50 years such that it now represents a safe investigation of particular use both when looking for a specific group of diagnoses and the most effective way of detecting rejection in the transplanted heart. Nevertheless, it is not without risk and its implementation varies widely between centres.

A joint scientific statement from the American Heart Association (AHA), the American College of Cardiology (ACC) and the European Society of Cardiology (ESC) published in 2007 remains the core of current guidance, but concedes that large-scale randomised data are scarce and some recommendations are based on accumulated expert opinion. 1 However, experts do not always agree, as demonstrated by recommendations in two contemporaneous consensus documents. The 2013 statement from the ESC Working Group on Myocardial and Pericardial Disease recommends EMB for the majority of cases where myocarditis is suspected (level of evidence C), 2 while the 2013 ACC/AHA Guideline for the Management of Heart Failure recommends EMB should not be performed in the routine evaluation of patients with heart failure (level of evidence C). 3