histopathology

REVIEW

National guidelines for adult autopsy cardiac dissection anddiagnosis – are they achievable? A personal view

S K SuvarnaDepartment of Histopathology, Sheffield Teaching Hospitals, Sheffield, UK

Suvarna S K

(2008) Histopathology

National guidelines for adult autopsy cardiac dissection and diagnosis – are they achievable?A personal view

Adult autopsy cardiac pathology has been previously aquiet backwater of ischaemic heart disease and theoccasional cardiomyopathy. This has changed to anincreasingly tense area, following recent genetic dis-coveries and some medicolegal cases. All autopsypathologists should consider their dissection protocols

and check that they are able to deliver the increasinglydetailed information that clinicians, geneticists andfamilies require. This text has suggestions about thepractical realities of cardiac dissection, cardiac histol-ogy and the need for other tests alongside illustrationsaimed to assist case consideration.

Keywords: autopsy, cardiomyopathy, heart, sudden adult death syndrome

Abbreviations: Ao, aorta; AoV, aortic valve; AV, atrioventricular; AVN, atrioventricular node; BB, bundlebranches; CxA, circumflex; Diag, diagonal; EVG, elastica–Van Gieson; GMC, General Medical Council; GUCH, grownup congenital heart disease; H&E, haematoxylin and eosin; HisB, His bundle; IVC, inferior vena cava; LA, leftatrium; LAD, left anterior descending; LIMA, left internal mammary artery; LMS, left main stem; LV, left ventricle;LVOT, left ventricle outflow tract; MV, mitral valve; OM, obtuse marginal; PA, pulmonary artery; PAS, periodicacid-Schiff; PIVD, posterior interventricular descending; PV, pulmonary valve; RA, right atrium; RCA, rightcoronary artery; RV, right ventricle; RVOT, right ventricular outflow tract; SADS, sudden adult death syndrome;SAN, sinoatrial node; SVC, superior vena cava; TV, tricuspid valve

Introduction

The impetus for review of autopsy methodology forcardiac diagnosis have been gathering for some time.Starting from aspects of Alder-Hey and Bristol, throughconsiderations of Coronial service review (now shelvedyet again) to the phased implementation of the HumanTissue Act (2004), with its requirement for licensing ofautopsy-related activities from 1 September 2006,autopsy practice has been under increasingly intensescrutiny. Other ‘drivers’ include the criticism of somepathologists’ autopsy practice in various National

Confidential Enquiry into Patient Outcome and Deathand Confidential Enquiry into Maternal and ChildHealth reports,1,2 clinical governance requirements toaudit certain categories of deaths, and National ServiceFramework cardiac disease framework documents3

setting treatment and outcome standards in cardiacdisorders known to cause sudden death. This has beenmatched by fast-paced technological developments incardiology,4 steady unravelling of the molecularpathology of cardiac disease5 and rising interest fromnational bodies6–8 that help families in inheritedcardiac disease.

While the Human Tissue Act (2004) lists activitiesrelating to the use of human tissue from the deceasedwhich require relatives’ consent,9 the performance ofcoronial autopsies – the bulk of UK pathologists’

Address for correspondence: S K Suvarna, Department of

Histopathology, Northern General Hospital, Sheffield Teaching

Hospitals, Herries Road, Sheffield S5 7AU, UK.

e-mail: [email protected]

� 2008 The Author. Journal compilation � 2008 Blackwell Publishing Limited.

Histopathology 2008 DOI: 10.1111/j.1365-2559.2008.02993.x

workload – falls outside its remit. In one GeneralMedical Council (GMC) case this year a pathologist wasseverely criticised for not retaining the heart andobtaining specialist cardiac opinion.10 In theory, reten-tion of tissues and organs from a coronial autopsywithout relatives’ consent is permissible under Coro-ner’s Rule 9, to confirm the cause of death.11 Inpractice, Coroners vary widely as to how they interpretthat rule, in many instances leaving it up to the familyto decide. Pathologists are thus caught in the middle12

and must be confident in making a case to retain, andpossibly refer, heart tissues in order to provide asaccurate a cause of death as possible.

All in all, it is time to review the objectives and themethods pathologists employ with autopsy practice andinterpretation of heart disease. All autopsy practitio-ners (qualified and in training) should be able toperform a sound review of the heart and its connectingvasculature – akin to the minimum dataset for a cancerreport. Previous work has covered some of the currentneeds, in the form of published guidance.13–18 Thismeans that, given the above drivers, any substandardor weak case analysis may not be tolerated medicole-gally in the future.

Certainly, knowledge of normal cardiac architectureand function is mandatory, and if this is weak thencorrective continuing professional development activityis needed. There is a balance to be derived between themajority of autopsy cardiac cases recognized to beroutine and those requiring greater consideration, asset out below. Thus, one might argue that many causesof ischaemic heart disease can be assessed ⁄ signedoff without written recording of every detail of thedissection as set out below. However, it is no longeracceptable to simply go ‘through only the basicmotions’ of cardiac dissection. Some consideredthought is required on every case. This document hastherefore been produced to aid processing of the‘routine’ case, and yet to prompt thoughts beyond justthe macroscopic autopsy and to facilitate later caseanalysis.

Preparation for the autopsy

Before putting knife-to-skin, knowledge of the patient’smedical history and interventions may be directlyrelevant to the dissection and interpretation. In manycases this history is lacking. However, this cannot beused as an argument to defend weak practice. Inter-action with the general practitioner, family andwitnesses is advised, particularly in cases of un-explained sudden death. Communication with relevantcardiac centres and access to clinical records may also

be needed. Of particular importance is good informa-tion pertaining to sudden deaths, and this should bederived from witness accounts if possible. Since manycases are derived from the Coroner ⁄ Procurator Fiscal,their assistance may be vital in securing data on thepathologist’s behalf.

Certainly, the consideration of consent and Coronialmedicolegal instructions is essential before the autopsy,and critical if considering retaining tissues. Specialistinvestigation preservatives and culture ⁄ transport med-ia, for the purposes of electron microscopy, microbiol-ogy and DNA extraction, should be considered prior tothe commencement of the dissection in order tooptimize sampling, and these should always be avail-able in a mortuary.

Digital photography is a quick and cheap adjunct toautopsy diagnosis, and camera facilities should beavailable in any mortuary. A digital image of mid-lowventricular transverse section ⁄ s and other views of theheart are very helpful as a record, and for referral.Indeed, they may obviate the need for retention of thewhole organ. Tissue retention of the whole organ isunderstood to be particularly problematic in some partsof the UK, reflecting individual Coronial jurisdictions.However, in sudden cardiac death organ retention andreferral should be regarded as the ‘gold standard’, withmany cardiac pathologists being prepared to examine,block and turn around cases with a few days. Familiescan be reassured that the bulk (usually more than 90%of the cardiac tissues) can be reunited with the body insuch circumstances.

Digital photography is not mandatory for all cases.However, in some cases the images may be a vital partof autopsy record and comprise part of the text reportas illustrations. It is advisable to consider ⁄ acquireappropriate consent for consent autopsies and toindicate to the Coroner that images have been takenin medicolegal cases. There is GMC guidance on thismatter.19 The author has not had any problems withregard to images being recorded and published (as inthis paper) provided that the case image is anonymousand the reasons for image capture are made clear at thetime to interested parties.

Referral pathways

Some cases can be handled by all autopsy practitioners,whereas others may benefit from wider discussionand ⁄ or referral. Most ischaemic and valvular heartdiseases can probably be dealt with by all qualifiedautopsy pathologists. However, trainees without theMRCPath (or equivalent) must have all cases checked,no matter what their seniority.

2 S K Suvarna

� 2008 The Author. Journal compilation � 2008 Blackwell Publishing Ltd, Histopathology

Complex cardiac disease, such as primary congenitalheart disease, grown up congenital heart disease (GUCH)or those cases with complex medical interventions

(electrophysiological surgery, mechanical assist devices,etc.) could be performed by general pathologists, butonly provided they feel confident on these problems.However, they are better placed in the hands of thosewith cardiac interest or specialist cardiac pathologists.

It is emphasized that sudden death, particularly inyoung individuals, requires very careful consideration,tissue retention and a wide range of investigations inorder to maximize the chance of obtaining a diagnosis.A wide range of scenarios is possible, as highlighted inthe College of Pathologist’s Cardiac Pathology AutopsyScenario, no. 113 (Table 1). Discussion of the case withthe family is often beneficial, particularly if there is apositive family history, and it is advisable to liase withregional cardiac pathologists.

Pathologists facing difficult cardiac autopsies, whichthey feel challenge their expertise, are advised not tostart such cases and are recommended to seek out ⁄request the Coroner to contact specialist cardiac pathol-ogists, possibly through a formal nationwide CardiacPathology Network.20 The Coronial system is aware ofthe realities of complex heart cases and it should not be aproblem for case triage and referral. This may occur atdifferent levels, depending on the issues being consid-ered and the skills of the individual pathologist.

The Cardiac Pathology Network is being set upwithin the UK, interacting with the Royal College ofPathologists and British Association of CardiovascularPathologists. A national database is being establishedfor pathologists to register cases of sudden cardiacdeath. The Network will also foster education on

Table 1. Causes of sudden cardiac death

Coronary artery disease and ischaemic heart diseaseAtherosclerosis

Structural ⁄ congenital malformation (includinganomalous origin)

Kawasaki’s disease

Myocardial bridging

Coronary artery dissection

Aortitis and secondary atherosclerosis

Embolism into coronary arteries

Fibromuscular dysplasia of intramyocardial artery

Coronary artery spasm (regional infarction inabsence of coronary lesion)

Valve diseaseAortic stenosis

Mitral valve prolapse

Infective endocarditis

Myocardial diseaseMyocarditis (including cardiac sarcoidosis)

Cardiomyopathies

Left ventricular hypertrophy and hypertension

Idiopathic myocardial fibrosis

Amyloidosis

Cardiac tumour – primary (myxoma) or metastatic

Structural conduction system abnormalitiesAbsence of atrial portion of atrioventricular node

Bundle of His damage

Nodal mesothelioma

Atrioventricular nodal artery stenosis

Anomalous conduction pathways(e.g. Woolf-Parkinson-White syndrome)

(NB diagnosis relies on ECG evidence in life or positivefamily history. Serial sectioning of conduction systemfor routine diagnosis is unnecessary)

Drug toxicityCocaine

Amphetamine and ecstasy

Solvent abuse

Marijuana6

Antidepressants and antipsychotics7,8

Table 1. (Continued)

No morphological abnormalities (SADS)Functional conduction system abnormalities (long QTsyndrome, Brugada syndrome)

Catecholaminergic polymorphic ventricular tachycardia

Idiopathic ventricular fibrillation

Blunt chest trauma (commotio cordis)

Other clinical scenarios in which sudden cardiac deathmay occur

Sudden death in athletes

SUDEP

Congenital heart disease (including GUCH)

Following cardiac surgery ⁄ interventions

Cardiac involvement in systemic disease (connectivetissue disorders, sickle cell disease, metabolic andendocrine heart disease)

Disseminated malignancy

National guidelines for adult autopsy cardiac dissection 3


cardiac pathology for pathologists and will establishlinks with the Department of Health, the Coroner’sSociety and the British Heart Foundation.

The autopsy

in situ macroscopic review

The heart should initially be examined in situ, havingexposed ⁄ opened the pericardium by removal of theanterior chest wall. At this point, one should sequen-tially examine the connections of the major arteriesand the gross external architecture of the heart andthe pericardium. This should be accomplished beforeremoval of the heart from adjoining structures. Anygrafts [e.g. left internal mammary artery (LIMA), veingrafts] and electrical pacemaker connections should beidentified and preserved intact with the cardiac tissue.Any effusions and ⁄ or blood collections should berecorded in terms of volume and character.

Open the pulmonary artery (PA) about 20 mmabove the valve and follow with fingertip palpationwithin the proximal internal PA trunk (to avoiddisrupting and missing proximal pulmonary emboli).Then transect the aorta (Ao) and PA. Transect thesuperior vena cava (SVC) at least 10 mm above theatrium and SVC interface, preserving the sinoatrialnode (SAN; Figure 1). One should now lift the apexof the heart upwards in a cranial direction, allowingtransection of the four pulmonary veins and theinferior vena cava (IVC), making sure that the posterioratrial wall and septum are kept intact with the heart.

The heart should again be considered from anteriorand posterior aspect to assess whether the arrangementof the atria and ventricles is normal. The right and leftatria have a triangular and rectangular appendagearchitecture, respectively. The right ventricle should beof palpably less thickness than the left, but bothventricles should be more precisely and objectivelymeasured, as below. At this point it is possible to openthe back of the right atrium [RA; along the posteriorwall of the septum in a line from the IVC to the SVC;and 10 mm parallel to the posterior wall ⁄ septuminterface on the left atrium (LA) after opening acrossthe LA roof between the pulmonary veins] in order toinspect the superior aspect of the tricuspid valve (TV)and mitral valve (MV), but do not cut into ⁄ across thevalve rings (Figure 2).

The coronary arteries

The prime object is to consider the course andarchitecture of the coronary arteries. Any abnormali-

ties should be recorded, and ideally photographed(Figure 3). It is recognized that some coronary arteryvariations are particularly associated with suddendeath.21

Figure 1. A referral fixed heart showing the crista of the right

atrium (RA) and the superior vena cava (SVC). The position of the

sinoatrial node (SAN) is indicated (*) along with black lines indicating

where cuts should take place to excise this tissue (black lines).

The piece of tissue should be sectioned along the line of blood flow

(i.e. longitudinally). For histology see Figure 12.

TV

MV

*

Figure 2. Opened atrial chambers showing the intact normal

tricuspid valve (TV) and trabeculated auricle; and mitral valve (MV)

and left appendage from above.

4 S K Suvarna


The internal aspect of the coronary arteries shouldbe assessed by stepwise transverse slices at no morethan 5-mm intervals (Figure 4). All of the coronariesshould be assessed, and this means not just the easilydiscerned large branches. It is generally agreed thatcutting coronary arteries longitudinally can disruptthrombi or emboli and make assessment of stenosisdifficult. A sharp scalpel blade is essential.

The coronary artery procedure will be more difficultwith heavily calcified vessels. In such circumstance thesolutions include, first, using scissors for the transversecut. Although quick, this will distort (and possiblydestroy) the inner plaque and any potential thrombus.However, it is a realistic solution in many cases, andyet must be balanced against the ideal of calcifiedcoronaries being dissected from the heart en bloc,decalcified overnight and then serially sectioned asstandard. The tissues may thus be returned to the bodythe next day. These options should be considered anddiscussed with the Coroner ⁄ family where relevant, butusually the decalcification ⁄ cut ⁄ return next day proto-col should not create any tissue retention issues.

In practice, inspection and cutting are nearly simul-taneous, and a standard system will reduce missedareas of tissue. I recommend starting the transversecuts in the middle of the left anterior descending (LAD),sweeping downwards towards the apex, then upwardstowards the left main stem (LMS) orifice. Thereafter,identify and examine the circumflex (CxA) and localbranches [diagonal (Diag) ⁄ obtuse marginal (OM)

1 ⁄ OM2]. Finally, the right coronary artery (RCA) inthe sulcus between the atrial appendage and rightventricle should be examined with similar cuts aroundthe right side of the heart towards ⁄ along the acutemarginal and posterior interventricular descending(PIVD).

It is possible to remove small segments of artery, ifthe case is to be demonstrated to clinicians or inexamination scenarios. However, if there is a possibilitythat subsequent ⁄ second autopsy examination mayfollow, then no tissue should be separated from theheart unless it is to be reserved for histology. If areas ofinterest are left in situ, it is always possible to markareas of interest with small sutures ⁄ clips.

Stenosis is probably best measured by an estimate oflumen area ⁄ total coronary area. This is to a degreesubjective, but stenosis >70% correlates reasonablywell with the probability of sudden ischaemic car-diac death.18,22,23 One should recognize that milderstenoses do not exclude ischaemic pathology taken inisolation, since they may have produced local throm-bosis and sudden high-grade artery obstruction, withfatal consequences. Stenoses may alternatively bequantified as diameter of lumen at the point ofmaximum disease, and lumens of £ 1 mm are associ-ated with the risk of cardiac arrest.18,22 In somecomplex cases it may be best to dissect free thecoronary arteries intact, decalcify and serially sectionat 5-mm intervals, thereby providing a better overview(Figure 5).

Coronary metal stents are increasingly common,and cannot be dissected with scalpel or scissors. If thestent requires investigation of the lumen then thisshould be removed en bloc for resin embedding and

PA

TV

Figure 3. A previously dissected and fixed heart showing the right

ventricle (RV) and pulmonary artery (PA) with an anomalous left

main stem (LMS) origin (arrow) from the PA in young female case of

sudden death.

Figure 4. Regular slices are made along the coronary arteries at

5-mm intervals. The left anterior descending (LAD; arrowed) is

running from the scalpel blade position off towards the 3 o’clock

boundary, with the Diag running from the mid section of the LAD

towards 1 o’clock.



subsequent specialist cutting microtomes (Figure 6).I am fortunate to have this available locally and sothis is my personal experience, but in reality it maytaken up to 1 month for sections to be available.Otherwise, up ⁄ downstream artery analysis usuallysuffices, with the proviso that gentle syringe injectionof water along the stented vessel will identify block-age ⁄ free flow. Some advocate, in the absence of resinembedding and specialist sections,24 that it is reason-ably informative and practical to peel the coronarywall around off the stent, visually inspect and gentlyretrieve in-stent material for additional histologicalevaluation (whether it is thrombus or restenotic

tissue). However, this creates a whole host of artefactsand could be criticised. In cases where legal consider-ation of the device is paramount, then resin embeddingis advised. Plain X-ray techniques are useful, particu-larly with cases where the stent position is not knownor where there are overlapping or branching stents(Figure 7).

The myocardium

Immediately after the coronary examination, unlessthere are other considerations such as congenital heartdisease, three transverse slices of ventricular tissues(approximately 10–15 mm thick) should then be takenstarting at the apex and finishing close to the base ofthe papillary muscles, making sure that the TV and MVtissue is not damaged. Areas of infarction and scarringmay be evident immediately, and mid-transversechamber views may be photographed, giving aclear indication of ventricular chamber architecture(Figure 8).

If there is any suspicion ⁄ data to suggest a cardiacanomaly ⁄ malformation, I recommend that the threetransverse slices are not taken initially, but rather oneshould open the myocardium ‘along the line of bloodflow’ to inspect the heart cautiously. Later, if desired,‘superglue’ will allow re-sealing of the myocardium andpermit one to perform the transverse slices.

If there is suspected pathology to the TV or MV thendirect inspection of the ventricular aspect is possibleat this point without further cuts. However, usuallyfollowing the transverse cuts, the RA and rightventricle (RV) may then be fully opened continuingalong the posterior wall of the RA into the RV just nextto the septum, approximately 10 mm to the side of the

Figure 6. A resin-embedded artery showing well-deployed wire

struts deforming the artery wall and creating a wide lumen. This is

a good technical result from angioplasty and stenting.

CXA

OMI

LAD

RCA

PIVD

*

Figure 5. The major branches of the coronary tree have been

removed, decalcified for 48 h and then sectioned. This allows clear

assessment of vessels and overview of the pattern of atheroma. The

arteries are marked and run from the left side of the image in

sequential fashion in serial slices. The maximal stenosis (*) is seen in

the left anterior descending (LAD) territory.

Figure 7. Heart radiology showing position of stented vessels.

6 S K Suvarna


PIVD. This posterior approach allows direct inspectionof the complete TV, atrial ⁄ auricular and ventriculartissues (Figure 9). At this point, inspect, but do notmake any further slice into the auricle.

The cut should then be continued round onto thefront of the RV and upwards through the rightventricular outflow tract (RVOT) and pulmonary valve(PV) (Figure 10). The circumferences of the TV, PV andthickness of the RVOT should be considered ⁄ recorded,along with other comments with regard to fattyinfiltration25 (Figure 11), thrombus, vegetation, etc.

The left side chambers are similarly inspected, withthe cut continuing from the posterior low LA into theleft ventricle (LV) 10 mm parallel to the PIVD. Thisallows direct inspection of all the left-sided chambersand auricle, again without cutting into the auricle(Figure 12). It is possible to lift the MV at this point andinspect the aortic valve (AoV; Figure 13). However, the

incision is now extended onto the anterior aspect of theLV to run along the edge of the anterior free wall,parallel to the LAD, until just under the anterior leafletof the MV – without damaging this valve. Thereafter,scissors are usually required to produce a partial right-hand turn, cutting between the base of the left auricleand immediately behind the LMS, thereby opening intothe left ventricle outflow tract (LVOT) and Ao, throughthe AoV (Figure 14). The position of the ostia andtheir patency should be assessed. The MV ⁄ AoV cir-cumferences and LVOT thickness should be consid-ered ⁄ recorded. It is advisable to avoid the lateralapproach to the left ventricular tissues and ⁄ or slicing

R L

Figure 8. The three transverse slices are examined with the right

side myocardium on the left hand aspect, akin to computed

tomography style with right and left side indicated. The overall

architecture of the chambers is apparent.

*

Figure 9. The opened right atrium (RA) and right ventricle (RV) are

seen with the auricle being easily inspected (*). There is no need to

further incise the RA appendage. The fossa ovalis is closed (arrow).

Figure 10. The right ventricular outflow tract (RVOT) is opened and

should be measured in thickness. This case had a background

pulmonary disorder with some thickening of the RVOT due to

pulmonary hypertension. Attention should always be paid to the

presence of fibrosis or fatty tissue.

E

*

Figure 11. The free wall of the right ventricle (RV) may have a

variable thickness of fatty wall tissue (top image), often under-

appreciated until histology. The histology (bottom) shows the normal

fatty wall structure from the epicardium (E) to the chamber lumen (*).



into the aortic root through the MV, as later consid-eration ⁄ demonstration of pathology is more difficult.Photography of the chambers and valves is ideal at thispoint, and consideration of atrial and ventricular septaldefects should occur at this juncture.

Once the heart has been fully opened in this fashionit is possible to weigh the tissues, with subsequentcross-comparison against standard charts for bodymass and sex.14,17 It should be noted (with regard toreferred cases) that fixation may increase heart weightby up to 5%. It is also possible to inspect closely thevalves and to record ring circumferences, if relevant.If there is fibrosis, distortion, calcification or otherpathology then this should be defined.

When considering global ventricular architecture ithas been suggested that measurement of ventricular

wall thickness is a useful tool to assess cardiachypertrophy and chamber overload. Given that thewall of either ventricular chamber is not uniform andsince pathologists tend to choose rather arbitrarypoints to measure wall thickness, one may have issueswith this protocol. Personally, I do not recommend thisas a solution and prefer to measure the RVOT andLVOT 10 mm below the valves (although not stringent,I have found it is less prone to variable recording).

One can also consider dissected ventricle weights,but this should not be employed unless this is the veryfinal task and with clear acceptance that the heart willbe rendered fragmentary with this examination. Itshould not be employed in cardiac pathology cases, ifreview will take place. The original description was onfixed tissue with all the fat stripped from the myocardialparenchyma. A fresh tissue assessment is possible, butone must remember that this once-only protocol doesnot permit secondary examination of cardiac tissue.Nevertheless, fresh tissue weights of the separatedventricular parenchyma may be of particular valuewhen considering cardiac hypertrophy, although Igenerally reserve this only for considering cardiacremodelling in lung disease cases. In addition, forconsideration of cardiac hypertrophy ⁄ failure, thetransverse chamber diameter for the right and leftventricles may be of assistance in assessing the degreeof cardiac status.

From a pragmatic stance, there are a variety ofoptions available when assessing hypertrophy, and thechoices ⁄ methodologies used should be made on anindividual case basis.14,26

LA

LVRV

RA

Figure 12. The left atrium (LA) and left ventricle (LV) can be seen

from the posterior aspect, along with part of the right side tissues.

It is not necessary to further incise the LA auricle, as the content

can be directly viewed.

MV

Figure 13. The mitral valve (MV) can be lifted gently using forceps to

inspect the aortic valve (AoV) inflow (arrow). The superior aspect can

be seen from the transected aorta (Ao). Given the significance of

pathology at this position, it is important to consider the state of the

valve before any further cut is made.

LMS

auricle

CXALAD

Figure 14. The left ventricular outflow tract (LVOT) and aortic valve

(AoV) are best examined after opening the heart from the front. Note

the arteries run as indicated in the image (red lines), and the cut

(black lines) is best made with scissors running upwards and between

the left atrium (LA) appendage and behind the pulmonary artery

(PA). Note, care is required not to damage the mitral valve (MV) as

one begins to make the turn of the cut towards the aorta (Ao).

8 S K Suvarna


Once the macroscopic detail of the coronary arteriesand myocardium has been considered, it is thenpossible to serially slice all the tissues of the ventriclesand septum at 5- to 10-mm intervals in order toexclude small focal lesions. These fine cuts should notbe performed if one is wishing to demonstrate the caseto other pathologists, or before photography has beenaccomplished, as this significantly distorts myocardialarchitecture.

Finally, it should be remembered that the apprecia-tion of myocardial tissue phenomena may be moreapparent after fixation, and one should ideally performboth fresh and fixed examination if such opportunityexists.

Histopathology

tissue blocks

Tissue blocks should be taken only from areas ofmyocardial tissue of relevance, and it is essential torecord the site of sampling. The choices must reflect theneeds of the case and the underlying pathology, as wellas other factors such as tissue retention. The scenariosare diverse, but can be considered in the followingschema, although it should be remembered that eventhe most stringent blocking will sample only about10% of the organ mass, leaving 90% for return to thebody if desired.

I have only occasionally used frozen section atautopsy, mainly for unexpected cardiac ⁄ pericardialtumours or to consider a possible myocarditis, beforechoosing how to sample a case. However, in practicalterms I do not recommend this as standard practice.

Routine histology stains

In general terms, routine haematoxylin and eosin(H&E)-stained 4-lm sections are sufficient, althoughthe Masson’s trichrome is very useful in differentiatingmyocytes from local interstitial parenchyma. Addi-tional histochemistry should be available to examineconnective tissue and intracellular components ofmyocardial parenchyma using periodic acid-Schiff(PAS), diastase-resistant periodic acid-Schiff, elastica–Van Gieson (EVG)+ ⁄ ) Alcian Blue, Congo (or Sirius)Red at 10 lm, Perl’s, and Toluidine Blue (note: at leastone myocardial block should have all these stainsperformed). Consideration of myocarditis can be enor-mously enhanced by staining for CD3+ and CD68+cells using standard immunohistochemistry and scoredper mm2. Specifically for the valve and coronarytissues, the use of an EVG (often combined with an

Alcian Blue) is important alongside the standardH&E. The possibility of valve sepsis requires martius ⁄scarlet ⁄ blue, Gram, PAS, Grocott, Gimenez and occa-sional Ziehl–Neelsen stains for full analysis.

Electron microscopy may have a role rarely in somemyopathic conditions and mitochondrial disease, andmay require a sample to be taken.

Histology in cases with a ‘normal’ heart(i.e. pathology elsewhere)

It may not be required to sample heart tissue forhistology or other test, unless an underlying ⁄ occultdisorder is suspected (e.g. metabolic disorder ⁄ myocar-ditis), or to prove the heart was normal. It is empha-sized that cases without apparent cardiac pathology,such as those where the pathology is clearly evident inother systems, should still have the above carefulexamination of the coronary artery system, myocardialtissue, valves and overall architecture balanced againstthe history. The possibility of microscopic disease mustbe weighed up carefully before electing to take no hearttissue for testing.

Histology for macroscopic cardiac pathology

In cases with primary ⁄ secondary cardiac disease (mostcommonly coronary artery disease and myocardialischaemia ⁄ infarction) it may be sufficient to fullyexamine the tissue macroscopically, record the degreeof vascular occlusion ⁄ stenosis as a percentage, statethe site ⁄ size of infarction and ⁄ or areas of patchyfibrosis. Phrases such as ‘moderate atheroma’ or‘patchy infarction’ are of little use without somequalifier of size and location. Cases that may be subjectto later medicolegal review should ideally be photo-graphed (Figure 15).

Well-defined myocardial ischaemic damage does notautomatically require histological sampling as part ofthe autopsy analysis, unless there is an issue thatrequires histological assessment (e.g. dating of infarc-tion, exclusion of other myocardial disease). In suchcases sampling should evaluate both the pathologicaland normal tissues. Thus, background coronaryartery ⁄ maximal area of stenosis (with decalcification)and damaged myocardial tissue will be taken – oftensufficient with one to four blocks.

Cardiac involvement due to systemic disease(Table 1) often requires thorough tissue sampling.Although one to two blocks might suffice, widersampling may be governed by the nature of dis-order and ante-mortem pathophysiology if clinical



correlation is sought. Thus, metastatic disease to theheart could require just one block, but consideration ofgranulomatous myocarditis, drug toxicity, lysosomalstorage disorder, etc., may need up to six blocks, or thespecialist investigations as detailed below.

With valvular heart disease the choice of how muchtissue needs sampling will reflect the pathology present.However, one to three blocks will normally be ample(normal valve, abnormal valve myocardium). Onoccasion, examination of all the valvular tissue andhinge point histology may be required, with carefulexcision, decalcification and histology. Microbiologysampling, if considered, should always precede histol-ogy samples.

Assessment of the great vessels is occasionallyrequired and in most circumstances focused on theaortic root and valve (rheumatoid disease, ankylosingspondylitis, syphilis, infective endocarditis, etc.). Blocksampling along the line of blood flow and use ofconnective tissue stains are very useful in thesecircumstances.

Histology in sudden adult death syndromeand the cardiomyopathies

Such deaths without clear macroscopic pathology arecomplex and often require consideration of neuro-muscular disorders, toxicology and genetic ⁄ moleculardisorders, as well as the cardiac pathology issues.5,27,28

To do less might be considered as suboptimal and mightbe challenged at a later date. Focusing solely on theheart, such cases may require ideally referral of the

intact heart for specialist cardiac pathology review, andit is wise to consider this even before starting theautopsy. Indeed, it is unwise to proceed in a recklessfashion ‘in the hope that it will turn out to be coronaryartery disease’!

The various cardiomyopathies are better recognizedand understood today. Given the impact for familiesand the prognostic issues, it is stressed that somereview of potentially deadly disease occurs beyond thestatement that ‘the case was a cardiomyopathy’. Moreis expected. Classic examples of hypertrophic cardio-myopathy, dilated cardiomyopathy and arrhythmo-genic right ventricular cardiomyopathy (but includingits variants) should be well recognized, although rarerexamples will be found in texts.28 However, somepatients, and kindreds, are unique and a certain rigouris needed for full assessment.

For these cases I would recommend the involvementof cardiac pathologists or formal Cardiac PathologyNetwork collaboration. Detailed family ⁄ drug historydata29–31 and results of prior investigations are likely tobe pertinent. It is certainly outside the scope of thispaper to cover this area in detail, but a workingknowledge of standard cardiomyopathy is needed if anyautopsy practice is to be undertaken. As with thesudden adult death syndrome (SADS) cases, it isexpected that widespread mapped blocking, photo-graphy and the other related tests are considered ⁄employed in order to maximize the data yield.

The standard autopsy examination should be aug-mented by photography, toxicology and thoroughhistology sampling. Microbiology and DNA testingmay be relevant. The blocks (with the stains as detailedabove being regarded as mandatory) should alwaysreflect the consent ⁄ Coroner’s realities, but ideallyshould be standardized. One would be criticized forsuboptimal sampling of a gastric or lung cancer, sowhy be different for an autopsied heart? My sug-gested ⁄ usual pattern of blocking is indicated in paren-theses, and it might be argued that some conformityshould occur (at least within the UK).

1 Coronary vessels (blocks 1–3 = LMS ⁄ LAD, RCA ⁄PIVD, CxA ⁄ OM1).

2 Conduction system [blocks 4 + 5 = SAN, 6–12 = atrioventricular node (AVN) ⁄ His bundle (HisB) ⁄bundle branches (BB), 13 = septum TVs].

3 Atrial tissue (block 14 = right ⁄ left).4 LV ⁄ RV septum lower (block 15).5 RVOT (block 16).6 LV anterior (block 17).7 LV lateral (block 18).8 LV apex (block 19).9 LV posterior (block 20).

Figure 15. Infarcted posterior right ventricle (RV), left ventricle (LV)

and septum with rupture of wall by previously correctly placed

pacemaker wire. In this scenario the disease of transmural infarction

is the cause of the wire penetration and cardiac tamponade, and

not poor placement of the pacemaker electrode.

10 S K Suvarna


10 Full mid-ventricular views of the right and leftventricle ⁄ septum, by the use of ‘jumbo’ blocks (blocks21–23) – these large blocks, obviate the need formultiple small blocks and provide a good geography ofventricular tissue.

It is prudent also to sample fresh spleen tissue (about20 mm3), which should be sent fresh to the localmolecular cytogenetics unit immediately for DNAextraction, etc. One should also reserve a small amountof myocardial tissue for electron microscopy intoglutaraldehyde.

It is advised that one gathers all information possiblefrom the family doctor, hospital records and family. It isrecognized this may be a burden, but pathologists couldbe putting themselves in jeopardy if they ignore thechance to obtain vital data.

Conduction system histology

There are broadly two schools of thought on this issue:those that do this technique regularly, and those whodo not perform the analysis, believing it is rarely of use.Belonging to the first group, it has been rewarding tofind a cystic atrioventricular tumour, granulomatousinflammation, calcification, lipo-atrophy of myocytes,etc., when looking at conduction systems in the last5 years. Although it is clear that the novel diagnosisyield is low, at least one can feel confident with thetechnique if regularly practised!

The cardiac conduction system cannot be discernedmacroscopically. There are a variety of texts on thematter,16,17,32 although the illustrations in the lateProfessor Davies’ 1985 atlas are very good.32 Conse-quently, wide blocking of tissues to ‘capture’ areas ofrelevance is required, and access to the whole heart isneeded. Once performed, the significant tissue samplingmeans further macroscopic appreciation will be ham-pered unless photographs are taken beforehand.

The SAN is found at the apex of the crista of the rightauricle and SVC interface (Figure 1). This block oftissue should be removed in an oblong piece of tissueand longitudinal slices along the line of blood flow willallow identification of the nodal tissue next to the SANartery (Figure 16). The tissue is composed of a ratherhaphazard group of mid-sized myocytes with localganglion cells and very slight fibrosis.

The AVN is found at the apex of the triangle of Koch(bounded by the superior limb of the coronary sinus,membranous septum and superior edge of the TVleaflet). This is best removed in a square piece and thenblocked in sequential stepwise slices right to left in alongitudinal fashion (Figure 17). The AVN myocytesshow a similar histology to the SAN.

This process will also allow identification of the BBs,HisB and AVN, as one progresses in blocks from left toright (Figure 18). However, step sections through the

Figure 16. Sinoatrial node (SAN) histology showing the irregular

nodal tissue and artery (arrowed) adjacent (H&E).

AVN

Figure 17. The right atrium (RA) and right ventricle (RV) view

here allows identification of the triangle of Koch (green lines) and

the likely position of the atrioventricular node (AVN). The HisB and

bundle branches (BB) lie immediately below and deep to the AVN.

To examine these fully one needs to resect a square of tissue (black

lines) to encompass all the conduction system elements. The slices

taken in the short (superior–inferior) axis should incorporate the fatty

atrial parenchyma, the membranous septum and the top of the

muscular septum (lower right inset).



paraffin blocks may be needed for full appreciation ofthe tissues. The radiating fibres of the BBs can be bestappreciated by a transverse block of the high septum.One should note that the BBs do not map to theidealized scheme that most ECG texts suggest!

Cardiovascular devices

Temporary and permanent devices are increasinglycommon in autopsy practice. Indeed, this is an evolv-ing arena and what will be available in the next5–10 years cannot be predicted. Ante-mortem data areoften paramount in appreciating issues before theautopsy (e.g. defibrillator pacemakers, vi). However,the examination should follow the above standardprotocols. Issues relating to medical and surgicalinterventions with the complications ⁄ successes pro-vide feedback for clinicians, relatives and those withmedicolegal interest. Likewise, knowledge of thecardiac intervention undertaken, for what primarycardiac disease and whether any complications havefollowed, is vital beforehand to maximize data retrievalfrom autopsy examinations.

Vascular access lines

These lines should be inspected at the time of autopsycommencement externally, cut flush with the skin andleft so that internal positions can be checked duringsubsequent organ dissection. Exclusion of thromboticchange and sepsis around the site of introduction mayrequire microbiological sampling and occasionallyhistology. Significant complications, such as massive

bleeding or cardiac trauma, should have photography(Figure 19).

Pacemakers

Cardiac pacemakers are increasingly frequent(Figure 20) and almost all appear to be reliable. In apersonal review of more than 500 units removed afterdeath, I have found only one with a ‘end of life battery’and none with abnormal program parameters. How-ever, the pacemaker box should ideally be returnedto the local ECG ⁄ cardiac pacemaker department for

Figure 18. The radiating bundle branches are seen in longitudinal

section here (arrowed). The Masson Trichrome is particularly useful

in highlighting cardiac myocytes within fibrous parenchyma. Figure 19. Attempted drainage of a loculated pericardial effusion

resulted in perforation of the heart by two drainage lines with a fatal

consequence.

Figure 20. Twin lead permanent pacemaker insertion points to allow

more ‘physiological heart pacing’. Note the three transverse slices

have not been used in order to preserve the overall view of the

chambers.

12 S K Suvarna


assessment and case audit,33 with about 10 cm of thelead still attached at least. The most likely scenario ofpathology for pacemakers is that of architecturalpathology. Exclusion of haemorrhage and sepsis (usu-ally around the time of implantation ⁄ battery change),lead fracture, thrombosis around lines and infectiveendocarditis at the lead insertion point ⁄ s is required.Ideally, the pacemaker box, its lead and electrodeshould be examined, preferably in one piece with thethoracic organ block.34 Suspected pathology may bethe driver for microbiology sampling, histology and ⁄ orphotography as appropriate.

An implanted cardiac defibrillator must be switchedoff before autopsy manipulation or removal, to avoidthe risk of accidental discharge during the autopsyprocedure.35 These devices are designed to generatehigh-voltage shocks in response to cardiac dysrhyth-mias. The clinical notes and ⁄ or family doctor shouldhave paperwork with regard to the pacemaker devicemodel. The local pacemaker clinic can then de-activatethe unit. Certainly, no pacemaker should ever be left inthe body, in order to avoid the risk of explosion atcremation.

Prosthetic valves

Valve replacement surgery broadly follows two pat-terns: those with tissue replacements (allograft orxenograft) or artificial devices (usually metal).36

Although primary valve replacement failure can occurdue to technical issues, the primary pathologies includelocal haemorrhage, infection, poor alignment, localleak and tissue overgrowth across the valve (pannus).It is not possible to open a prosthetic valve in a mannersimilar to native valve tissue. Consequently, cardiacdissection requires exploration of the valve from above,as well as from below, to assess carefully the valve andany pathology. Thus, opening an atrium along theposterior aspect alongside the septum, then turning90� to run the incision along ⁄ around the atrial baseimmediately above the atrioventricular (AV) groove toapproximately 50% of the atrial chamber is recom-mended for AV valve prostheses. The ventricles areexplored by opening the ventricular chambers from theapex of the heart, running a cut upwards adjacent tothe ventricular septum posteriorly and then turning90� towards the lateral aspect of the ventricularchamber, allowing the ventricular chamber to bedisplayed (Figure 21). For a PV or AoV prosthesis thedissection may largely follow standard parameters, butmust allow for below ⁄ above review of the prosthesis.

Finally, one relatively rare procedure for AV valves isprevious surgical valvuloplasty or partial prosthetic

valvuloplasty (Figure 22). Standard exclusion of infec-tive endocarditis and review of cardiac chamberanatomy are most important in such cases.

Other devices

Developments are ongoing, and these are increasinglycommon in cardiac tissues. Examples include, first,septal closure devices, which broadly comprise twoumbrella platforms that are placed across the septalleak (Figure 23). These should be inspected carefully asthe chambers are opened, with photography and

Figure 21. Suggested scheme to dissect the left atrium (LA) and left

ventricle (LV) in cases of mitral valve (MV) prosthesis, allowing

superior and inferior views to be examined. Solid lines are cuts on the

posterior face and broken line is continuation onto anterior aspect.

RA

RV

Figure 22. A partial ring tricuspid valve (TV) prosthetic valvulo-

plasty.



microbiology sampling as appropriate. Removal of thetissues intact with the device is indicated if medicolegalconsideration is to be made. Second, patch or vascularrepairs, comprising Dacron-style materials, may beseen in some cases (Figure 24). Attention to the suturepoints is particularly important, to exclude infectiveendocarditis. The standard advice regarding photogra-phy applies, alongside histology and microbiologyrealities. Finally, ventricular assist devices (temporaryand permanent) are becoming increasingly used as abridge for those awaiting cardiac transplant. If encoun-tered, then communication with the transplant centreregarding the best approach is strongly advised.

Ischaemic heart disease intervention

Surgical and medical intervention for ischaemic heartdisease is still common, albeit with open surgicaltherapy declining. In recent history, open surgicalcoronary artery bypass grafting was the norm forcoronary artery disease. In recent decades, the LIMAhas been increasingly used. As above, ante-mortemdata are very important, particularly knowledge of thenumber of grafts and the position to which they wereapplied. This can save considerable time when facedwith a severely fibrotic pericardial tissue background.

Clearly, technical problems, such as sepsis, haemor-rhage and infection, need documentation and possiblyphotography. One is naturally primed to review thegrafted vessels, their attachments ⁄ engraftments withconsideration of the background vasculature. This willrequire ideally transversely cut vessels from the aorticroot along the graft, or along the internal mammaryartery graft. Some advocate using scissors to dissectalong the vessel, provided that the lower part of thegraft has been opened to identify any extruded throm-bus ⁄ foreign matter, although this is clearly less rigor-ous. Any re-stenosis should be evaluated, and scored asfor native arteries. In addition, histological sampling ofthe ‘downstream’ myocardium is advised to considerischaemia pathology extent and chronicity.

Finally, the native vessel disease and possibleobstruction ⁄ thrombosis of the anastomoses must beassessed. If these are heavily calcified then they shouldbe dissected whole, decalcified and considered byhistology, although tissue retention issues are pertinentin deciding the dissection procedure employed (vs).As discussed earlier, coronary stents are increasinglycommon in autopsy practice, and are covered in theabove section on the coronary artery.

Other complex cases

Cases of cardiac transplantation and GUCH areideally considered by those with appropriate experi-ence and expertise. If appropriate consent andpermissions exist, the heart should be removed intact,washed through, fixed and dispatched for furtheranalysis. The tissues can be returned to the body onmany occasions, but this requires prompt access tothe Cardiac Pathology Network. The only alternativeis to extract, photograph and block the heart in themanner of SADS cases. DNA extraction and othertests may need to be undertaken. In general terms, Ialways recommend speaking with the family directlyif tissue retention is stated to be an issue. One can-not be criticised later if (possibly with a cardiac

Figure 23. Atrial septal device placed 5 years previously with good

effect, now sealed in by normal fibrous tissue and endocardial surface

tissues. The cruciate architecture can be made out below the surface.

Figure 24. An aortic root replacement with aortic valve (AoV)

prosthesis. Note the insertion points of the two normal coronary

arteries.

14 S K Suvarna


pathologist) one has attempted to advise the relativesof the need to keep tissues, they have elected toignore such advice and their decision has hamperedreaching a coherent and accurate cause of death.

Conclusions

This paper set out to review the guidelines that shouldgovern safe, appropriate and helpful autopsy practice inthe UK. In short, they are achievable whether one isworking in a general or teaching hospital. I suspectthey could be applied outside the UK, nevertheless. Thepaper is not an absolute set of rules, but rather strivesto develop ‘dataset’ concepts in this complex field.Ultimately, prosectors must chose for themselves whatthe case requires. One must choose carefully which ofthe above situations is applicable and how detachedthe final text report needs to be. This will reflect theindividual case history and findings.

There are several useful resources that are recom-mended. These include information from the RoyalCollege Pathologist’s website,13 and the Association ofEuropean Cardiovascular Pathologists’ SADS guide-lines.15 General and autopsy texts on cardiovasculardisease are recommended,37,38 and access to somespecialist publications is also helpful. Time spentbeforehand considering local contacts is valuable, andless stressful than if one is unprepared when a ‘hotcase’ is present in the mortuary.

In writing an autopsy report it is important not toforget the family. Inasmuch as pathologists needbackground data, the families of the deceased needfeedback. Some may occur via clinicians, but oneshould be prepared to meet relatives and to dis-cuss ⁄ explain the findings. These out-patient styleinterviews often take up to 1 h and are draining, but,in the author’s opinion, are part of the job.

It is expected that this document will need updatesand re-working along with developments of medicine,pathology, law, microbiology and genetics. However,the days of a substandard cardiac autopsy are over, andit is to be recommended that those active in this areadecide how they will deliver the modern cardiacpathology for the nation.

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histopathology

Documents

cardiac histology

sudden death

left ventriclelvot

sudden adult death syndromesan

inheritedcardiac disease

pulmonary valve ra

pulmonary artery pas

right ventricle rvot