Iatrogenic Right Ventricular Perforation Following an Endomyocardial Biopsy for Fulminant Myocarditis

Right ventricular (RV) perforation is a rare but potentially life-threatening complication of endomyocardial biopsy (EMB), particularly in patients with fulminant myocarditis, where myocardial edema increases myocardial fragility. We describe the case of a 50-year-old woman who developed acute RV free-wall perforation immediately after EMB performed for suspected fulminant myocarditis. Emergent pericardial drainage temporarily stabilized her hemodynamics, but ongoing hemorrhage necessitated urgent conversion to open surgical repair. A 3-mm perforation on the anterior RV wall was successfully sealed using a fibrin patch (TachoSil®) and a collagen-based hemostatic agent (Bolheal®), followed by extracorporeal membrane oxygenation support for circulatory stabilization. The patient recovered completely without recurrence and remained stable at the 10-month follow-up. This case highlights the need for early recognition of biopsy-related perforation, prompt surgical preparedness, and meticulous septal targeting during EMB, particularly in patients with myocarditis whose edematous myocardium is highly susceptible to mechanical injury.