After 17 years of private practice as a cardiovascular surgeon, my partners qu- tionedtherationalityofmydecisiontoleavetheclinicalpracticebehindandbecome acardiovascular pathologist. Infact, theirdisbeliefofmyintentiontomakethe"leap of faith" was understandable. For a surgeon, the operating room is where the action is. It is as simple as that. 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. However, life is complex. Throughout my surgical career, questions regarding the pathogenesis of atherosclerotic cardiovascular disease arose; curiosities of va- ous phenotypes of the disease piqued my interest. I became aware of the power of investigative techniques that might address these questions. I then began to realize that my career in the operating room left me little time to address them. I needed to study the disease full time in order to contribute to my understanding of it. Ironically, my ?rst autopsy as a pathology resident was on an individual with a past history of coronary artery bypass surgery. When it came to examining the heart, the dissection, as all pathologists know, was complex. However, I found it to be straightforward and enjoyable. But I subsequently learned that my fellow re- dents and mentors did not share my intrigue and comfort in de?ning the nuances of the operated heart.
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 related questions.
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