Cardiac Path Online

Heart Transplants - Pathological Examination

Dr Sampurna Roy MD

 

                                                                                                                      

 

 

Reporting of endomyocardial biopsy (Allograft rejection)

ISHLT system for grading rejection

Patients receiving heart transplants usually are in end-stage cardiac failure due to ischaemic heart disease or idiopathic cardiomyopathy.

Heart specimen is usually submitted fresh.

General outline for examination of heart 

The specimen usually consist of both ventricles and atria amputated 0.5 cm above the ventricles.

Occasionally, the pathologist will also receive small portions of the donor heart. (Example: Auricular appendages).  

Autopsy examination of heart

Processing the specimen:

(1) In general, hearts are cut after fixation in a manner dictated by the pathology to be demonstrated.

Hearts with dilated cardiomyopathy are cut longitudinally from apex to base, bivalving both ventricles and bisecting tricuspid and mitral valve (apical 4 - chamber cut).

Hearts with ischaemic heart disease are cut transversely at approximately 1 to 2 cm intervals beginning at the apex to the level of the mitral valve ("serially sectioned").

The base of the heart may be cut longitudinally or open according to the line of flow.

(2) Weight of the specimen. Normal weights for the entire heart are  270-360 g for males and 250-280 g for females. 

(3) Describe epicardial surface including pericardial fat (abundant, scant), petechiae , adhesions.   

(4) Describe each ventricle separately including hypertrophy or dilatation, fibrosis (endocardial, epicardial, transmural, location and degree), infarcts (old or recent, size, location, transmural or subendocardial ), trabeculations, papillary muscles (hypertrophied, thinned, scarred, infracted), presence of mural thrombus.

Measure the wall thickness or both ventricles. Normal thickness of the left ventricle is 0.9 to 1.5 cm and the right ventricle is 0.25 to 0.3 cm.

(5) Describe atria if there are any endocardial lesions.

(6) Describe any valve lesions as in section above (native or prosthetic).

(7) Atherosclerotic coronary arteries are dissected from the heart, fixed and decalcified and sectioned transversely at 3 to 5 mm intervals. 

Soft unobstructed coronary arteries may be carefully cut in transverse sections on the fixed heart at 3 mm intervals.    

Anatomy of the coronary arteries;

Autopsy examination of coronary arteries.

Describe the coronary arteries , percent of luminal compromise, location, recent thrombi or plaque  hemorrhage, and the locations of these lesions.

(8) Describe any bypass grafts including type (saphenous vein, left internal mammary), location of graft to native vessel patency.

(9) Describe amount and type of tissue taken for research, name of the principal investigator taking the tissue.

(10) Submit three sections of the left ventricular free wall (base, lateral and apex in one cassette), two sections from right ventricular free wall (base and apex in one cassette and two sections from the septum (base and apex in one cassette).

Additional cassettes are submitted to document native coronary arteries, coronary artery grafts and any other  gross lesions. 

                                                   

Complications of Heart Transplantation:

 

1) Acute rejection  ;  

2) Graft vascular disease  ; 

3) Infection  ; 

4) Drug side effect  ;  

5) Postoperative ; 

6) Neoplasia (EBV related lymphoproliferative disease)  ;

7) Disease recurrence in graft ; 

8) Systemic effect of underlying disease.

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)

 

 


 

 

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