Guidelines for autopsy investigation of sudden cardiac death: 2017 update from the Association for European Cardiovascular Pathology

Abstract

Although sudden cardiac death (SCD) is one of the most important modes of death in Western countries, pathologists and public health physicians have not given this problem the attention it deserves. New methods of preventing potentially fatal arrhythmias have been developed and the accurate diagnosis of the causes of SCD is now of particular importance. Pathologists are responsible for determining the precise cause and mechanism of sudden death but there is still considerable variation in the way in which they approach this increasingly complex task. The Association for European Cardiovascular Pathology has developed these guidelines, which represent the minimum standard that is required in the routine autopsy practice for the adequate investigation of SCD. The present version is an update of our original article, published 10 years ago. This is necessary because of our increased understanding of the genetics of cardiovascular diseases, the availability of new diagnostic methods, and the experience we have gained from the routine use of the original guidelines. The updated guidelines include a detailed protocol for the examination of the heart and recommendations for the selection of histological blocks and appropriate material for toxicology, microbiology, biochemistry, and molecular investigation. Our recommendations apply to university medical centers, regionals hospitals, and all healthcare professionals practicing pathology and forensic medicine. We believe that their adoption throughout Europe will improve the standards of autopsy practice, allow meaningful comparisons between different communities and regions, and permit the identification of emerging patterns of diseases causing SCD. Finally, we recommend the development of regional multidisciplinary networks of cardiologists, geneticists, and pathologists. Their role will be to facilitate the identification of index cases with a genetic basis, to screen appropriate family members, and ensure that appropriate preventive strategies are implemented.

Keywords: Autopsy; Guidelines; Protocol; Sudden cardiac death.

Fig. 1

After a transection of the aorta 3 cm above the aortic valve, inspection of the coronary ostia location in the proper sinus (LCA=left coronary artery; RCA= right coronary artery)

Fig. 2

a Schematic representation of serial cross sectioning of the sub-epicardial coronary artery tree. b A careful inspection of the serial sections is needed not to miss any coronary lesion. A transverse cut of the first tract of the left anterior descending coronary artery appears occluded by thrombosis.

Fig. 3

Short axis cross sectioning of the heart specimen from mid-ventricular to apical levels. a gross view of the specimen before cross sectioning. b transverse sections of the heart at the three different levels as represented in a

Fig. 4

a Sampling of the myocardium with several transmural blocks, circumferentially along the left ventricle, septum and right ventricle. b An additional sampling of the right ventricular outflow tract myocardium can be also taken