The Operated Heart at Autopsy

After 17 years of private practice as a cardiovascular surgeon, my partners qu- tionedtherationalityofmydecisiontoleavetheclinicalpracticebehindandbecome acardiovascular pathologist. And when a cardiac surgeon can hold in his hand a beating heart, now off-bypass and improved by an operation just completed, satisfaction is real and profound.

The Operated Heart at Autopsy addresses the need of pathologists in practice and, especially, in training to achieve a new level of competence in dealing, at the time of autopsy, with the anatomic complexity of a heart that has undergone previous surgical treatment, whether that treatment occurred in the recent or remote past. Ready identification of post-operative morphologic changes in the heart will greatly increase the comfort level of the pathologist as he takes on the challenge of the operated heart. By drawing on lessons learned as a cardiac surgeon, the author offers reasonable guidelines to the pathologist facing this challenging task. Such guidelines include a methodical approach to assess multiple operative procedures on the heart. Previous surgery may include construction of coronary artery bypass grafts (CABG), replacement or repair of one or more heart valves, repair of one or more congenital heart anomalies, or some other procedure. Questions will arise at such an autopsy. When a past medical history is lacking, what is the best way to determine exactly what operation was done? Was the cause of death heart-related? What was the impact of the heart surgery on the cause of death? What is the importance of technical issues of the heart surgery in a given autopsy? What steps should be taken in the actual dissection of the heart…and in what order? What are the anatomic landmarks, i.e., "footprints" of a surgeon, to look for when examining the operated heart? Importantly, as the pathologist in charge of an autopsy of an individual who died during or following open-heart surgery, what do I, the pathologist, tell the cardiac surgeon who needs to know what happened? The Operated Heart at Autopsy will definitely guide the pathologist, whether a resident in training or a professional in academic or private practice, in addressing these and other relatedquestions.