Table 3.

Autopsy procedures

Appropriate photographic documentation of the hearts is recommended
Handling of the heart: Remove en bloc the heart and lungs with the thoracic aorta for a proper complete evaluation. If a second opinion is sought the entire block, and not only the heart, should be referred (after washout)	Fresh heart Wash out to remove blood clots Put crumpled paper towels or gauze soaked in formalin in ventricle cavities to allow fixation without distortion Take small ventricle pieces to be frozen Put the heart in an appropriately sized container with sufficient 10% formalin to cover For proper valuation of surgical conduits and anastomosis, it is important to investigate the heart lung specimen, with large arteries (pulmonary arteries and aorta including aortic arch intact). When dissecting the heart, it is also important to keep the roof of the atria with inflow of the pulmonary and systemic veins intact
Gross examination before sectioning the heart	Describe the heart: dimensions (hypertrophic, dilated, normal) Consider a plain X-ray for localization of devices, catheters, calcifications, etc. Weight the heart Measure longitudinal distance (distance from the crux cordis to the apex on the posterior aspect) Transverse distance (from the obtuse to the acute margin along the posterior atrioventricular sulcus) Possible aneurysms Describe amount and distribution of epicardial fat Examine the atrial cuffs and atrial appendages for size, endocardial lesions and thrombi Examine atrioventricular valves (atrial view) and the semilunar valves (arterial view) and note any abnormalities (mention bicuspid valve)
Non-operated congenital heart disease
Sectioning	Before dissection, check whether the heart is biventricular or univentricular: with univentricular physiology, it is essential to identify the rudimentary ventricle Dissect the heart following blood flow (a transverse cut at mid-ventricle is not usually recommended)
Gross examination	Use the sequential segmental approach whose main steps are the following: Definition of atrial situs Morphologic identification of atria, ventricles and great arteries Recognition of atrioventricular and ventriculo-arterial connections
Sampling for histology	Sample left and right ventricle.
Operated congenital heart disease
General recommendations	Assess any devices, including valves and patches or biological grafts relating to previous surgical or interventional procedures. (endocarditis, thrombosis) Check for catheters within the cavities and epicardial leads
Sectioning	Structure of the heart can be markedly altered; it is advisable to have a clear idea of the primary disease and subsequent surgery before sectioning, if possible with the surgeon or cardiologist present.
Coronary arteries	Locate the coronary ostia and/or eventual aberrant course Make transverse cuts at 3-mm intervals in the main epicardial branches to identify atherosclerotic stenosis / occlusion (as usual)
Sampling for histology	A complete section of the heart at mid-ventricular level is not recommended In non-operated and operated hearts histological evaluation could be important for dating the injuries or thrombosis or any complications and for assessing the pathological substrates (fibrosis, ischemic injury, endocardial elastosis, scars), which may contribute to cardiac failure and/ or arrhythmias. I would recommend sampling of the heart for interstitial fibrosis and endocardial elastosis of the right and left ventricle. One sample from the right ventricle, one from the left ventricle.
Staining	When warranted by hematoxylin-eosin, stains for collagen and elastic fibers (Masson or Mallory trichrome, Movat pentachrome, Wiegert van Gieson, etc.) and additional stains or immunohistochemistry on indication