Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant (HTx) rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples have significantly improved diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (i) an overview of the practical approach to EMB, (ii) an update on indications for EMB, (iii) a revised plan for HTx rejection surveillance, (iv) the impact of multimodality imaging on EMB, and (v) the current clinical practice in the worldwide use of EMB.

Attikon University Hospital Department of Cardiology National and Kapodistrian University of Athens School of Medicine Athens Greece

Berlin Institute of Health Department of Cardiology Campus Virchow Klinikum Charite University Berlin Germany

Cardiology Clinical Academic Group St George's Hospitals NHS Trust London UK

Cardiopathology Institute for Pathology University Hospital Tuebingen Germany

Cardiovascular Pathology Unit Department of Cardiac Thoracic Vascular Sciences and Public Health University of Padua Padua Italy

Cleveland Clinic Cleveland OH USA

Department of Cardiology Clinical Center of Serbia Belgrade Serbia

Department of Cardiology Nagoya University Graduate School of Medicine Nagoya Japan

Department of Cardiology partner site Berlin; Charité Universitätsmedizin Berlin Germany

Department of Cardiovascular Medicine Charles University Prague Czech Republic

Department of Cardiovascular Medicine Faculty of Medical Sciences Kyushu University Fukuoka Japan

Department of Cardiovascular Medicine Kitasato University Kitasato Institute Hospital Tokyo Japan

Department of Cardiovascular Medicine Mayo Clinic Jacksonville FL USA

Department of Cardiovascular Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Okayama Japan

Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Osaka Japan

Department of Medical Sciences IRCCS San Raffaele Rome Italy

Faculty of Medicine University of Belgrade Belgrade Serbia

Fraunhofer Institute for Toxicology and Experimental Medicine Hannover Germany

Heart and Vascular Center Brigham and Women's Hospital and Harvard Medical School Boston MA USA

Heart and Vascur Institute University of Pittsburgh Medical Center Pittsburgh PA USA

Institute of Molecular and Translational Therapeutic Strategies Hannover Medical School Hannover Germany

Monash University Melbourne Australia

National Heart and Lung Institute Imperial College and Royal Brompton Hospital London UK

Serbian Academy of Sciences and Arts Belgrade Serbia

University of Warwick Coventry UK

Winters Center for Heart Failure Cardiovascular Research Institute Baylor College of Medicine Michael E DeBakey VA Medical Center Houston TX USA

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Long-term outcomes and reverse remodelling in recently diagnosed unexplained left ventricular systolic dysfunction