Heart autopsy

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Author: Mikael Häggström [notes 1]
Autopsy of the heart:

Comprehensiveness

Factors supporting a relatively more comprehensive autopsy and/or report, particularly in the inclusion of negated findings:

  • Lack of explanation from existing evidence. On the other hand, for example, upon finding an obvious aortic rupture, the rest of the autopsy is less relevant and may be relatively short.
  • Double-reading: If your report is likely to undergo double reading by another pathologist before sign-out, it needs to be more detailed, because the doctor who will do the double-reading then knows that you have looked at those locations.
  • Highly suspected locations, such as given from the referral.

In this page, the following signs and text coloring are used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Autopsy cutting checklist

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  • Remove the parietal pericardium
  • Separate the heart from the from lungs by cutting through the major vessels
  • Dissect the coronary vessels.More details in section below.
  • On the right side of the heart, dissect in the direction of blood flow: Superior vena cava > right atrium > tricuspid valve > right ventricle. Look for thromboses or patent foramen ovale.
  • Dissect the atrial appendages, to exclude thromboses.
  • Dissect the left ventricle, such as into circumferential slices from the apex to the base.[notes 2] Inspect (and measure) the left ventricular wall thickness.

In case of suspected infarction, see autopsy of myocardial infarction.

Left ventricular hyperthophy grading
by posterior wall thickness[1]
Mild 12 to 13 mm
Moderate >13 to 17 mm
Severe >17 mm

The average thickness of the left ventricle is up to 8 mm in women and 9 mm in men.[notes 3][2]

Gross examination of coronary arteries

Coronary vessels, with annotated arteries.svg

Make longitudinal (or transverse cuts at 3 mm intervals[3]) through:

  • The right coronary artery.
  • (The right marginal artery)
  • The left coronary and circumflex artery.
  • The left anterior descending artery.
  • (The left marginal artery)
  • (The left diagonal branch)
  • Any vessel grafts to the heart

Estimate the percentage of any significant stenosis or occlusion.

The presence of a totally occlusive thrombotic mass confers a diagnosis of likely sudden cardiac death death even in the absence of microscopically visible necrosis.[3]

Weight

Cardiomegaly can be defined as a weight exceeding the 95th percentile of normal individuals, preferably adjusted for weight, size, age and gender.[4][notes 4]

Weight of heart versus body.[5]

Microscopic examination

Myocardium

Look for:

  • Signs of myocardial infarction:

If one or more is present, see Autopsy of myocardial infarction

  • (Optionally, also look for:)

Reporting

This is en example report. In addition to comprehensiveness, it has the following annotations:
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Organs or important regions are in bold in this example for clarity, but does not need to be in an actual report.
edit
The heart << has normal weight / is enlarged [[ > 399 g in women and> 449 g in men]] >>, weighing ___ g.

Normal configuration (No atrial or ventricular dilation. No ventricular wall thickening) / {{The left ventricle has {{concentric}} hypertrophy, with a wall thickness of ___ mm.}} ((No atrial or ventricular dilation. The left ventricular wall thickness is __ cm and the right is ___

(Foramen ovale is closed.) ((The ductus arteriosus is obliterated))
The coronary arteries ((arise in normal position. They)) have << no / mild / moderate / severe >> {{and particually calcified}} arteriosclerosis, without significant constrictions. No thrombi in the cardiac atria (including auricles), chambers or coronary arteries.

Chordae tendineae, the endocardium and heart valves are unremarkable. (The endocardium is smooth and shiny. Chordae tendineae are unremarkable. The valves are normal in number, and are thin and fine at the openings.) ((The endocardium is smooth, transparent and free of mural thrombi. The valve leaflets and chordae tendinae are overall delicate, pliable and free of lesion or calcification. No signs of inflammation.
The valve ring circumference are: Tricuspid and mitral approximately ___ cm and aortic and pulmonic approximately ___ cm.
The epicardium and subepicardium are unremarkable.))

The myocardium has ((a homogeneous reddish brown color, and)) no signs of fresh lesion (or scar).

See also: General notes on reporting

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. An alternative approach is to cut the left ventricle through a cut along the left lateral margin, followed by an anterior cut from the apex to the aortic root, freeing the anterior wall. Then cut through the plane of the myocardium of the anterior and posterior myocardial wall, as well as the septum, for any signs of infarction. (Dissect one or more papillary muscles for infarction.)
  3. The numbers for the average thickness of the left ventricle are the 95% prediction interval for the short axis images at the mid-cavity level
  4. External link: Chicago model for post-mortem classification of cardiomegaly, adjusted for weight, size, age and gender.

References

  1. Goland, Sorel; Czer, Lawrence S.C.; Kass, Robert M.; Siegel, Robert J.; Mirocha, James; De Robertis, Michele A.; Lee, Jason; Raissi, Sharo; et al. (2008). "Use of Cardiac Allografts With Mild and Moderate Left Ventricular Hypertrophy Can Be Safely Used in Heart Transplantation to Expand the Donor Pool ". Journal of the American College of Cardiology 51 (12): 1214–1220. doi:10.1016/j.jacc.2007.11.052. ISSN 07351097. 
  2. Kawel, Nadine; Turkbey, Evrim B.; Carr, J. Jeffrey; Eng, John; Gomes, Antoinette S.; Hundley, W. Gregory; Johnson, Craig; Masri, Sofia C.; et al. (2012). "Normal Left Ventricular Myocardial Thickness for Middle-Aged and Older Subjects With Steady-State Free Precession Cardiac Magnetic Resonance ". Circulation: Cardiovascular Imaging 5 (4): 500–508. doi:10.1161/CIRCIMAGING.112.973560. ISSN 1941-9651. 
  3. 3.0 3.1 3.2 Michaud, Katarzyna; Basso, Cristina; d’Amati, Giulia; Giordano, Carla; Kholová, Ivana; Preston, Stephen D.; Rizzo, Stefania; Sabatasso, Sara; et al. (2019). "Diagnosis of myocardial infarction at autopsy: AECVP reappraisal in the light of the current clinical classification ". Virchows Archiv. doi:10.1007/s00428-019-02662-1. ISSN 0945-6317. 
  4. . Chicago model for post-mortem classification of cardiomegaly. Northwestern University Feinberg School of Medicine. Retrieved on 2020-01-15.
  5. Kumar, Neena Theresa; Liestøl, Knut; Løberg, Else Marit; Reims, Henrik Mikael; Mæhlen, Jan (2014). "Postmortem heart weight: relation to body size and effects of cardiovascular disease and cancer ". Cardiovascular Pathology 23 (1): 5–11. doi:10.1016/j.carpath.2013.09.001. ISSN 10548807.