Template for Autopsy Report in Adult Congenital Heart Diseases

The pathology report should include a descriptive section and the final diagnosis.

Descriptive section should include:

• A sufficiently detailed clinical history with the native congenital heart disease, time and type of surgical and hybrid procedures.

• Systematic description of the macroscopic findings at autopsy.

• Systematic description of the microscopic findings, if required.

• Description of any additional tests, if performed.

To understand the gross autoptic findings, the pathologist at autopsy should be aware of the cardiac morphology in the different types of CHD, the pathophysiology and the possible surgical or interventional techniques for palliation or repair. Microscopic and molecular findings should correlate to the macroscopic autopsy findings before interpretation can be finalized. Before the release of the report the pathologist should always discuss findings with the surgeon and the cardiologist.

Final diagnosis should include:

• Cause(s) of death.

• Description of the native congenital heart defect and status after surgical correction. (state remodeling of the heart, which includes also histological appearance, chambers after surgery, and other complications)

• Pathologic findings in order organs (in order of priority)

• Description of the surgical and interventional procedures

• Epicrisis or clinicopathological correlations and comments.