William The Coroner’s Forensic Files

Monday, 20, September, 2010

Graduate School #9 Examination of the Heart

Filed under: Forensics,Teaching — williamthecoroner @ 14:20

Examination of the heart

I.              Introduction

The specimen usually consists of both ventricles and atria and the attached aorta at the arch

II.           Processing the specimen:

  1. The pulmonary veins are opened in situ, to look for pulmonary emboli
  1. In general, hearts are cut fresh in a manner dictated by the pathology to be demonstrated.

1.             Infant and child hearts with dilated cardiomyopathy are cut longitudinally from apex to base, bivalving both ventricles and bisecting tricuspid and mitral valves (“apical 4 – chamber” cut).

2.             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” or “breadloafed”).

3.             The base of the heart is opened along the line of flow.

  1. Weight of the specimen.

1.             Males 350 gm +/- 40 gm

2.             Females 300 gm +/- 30 gm

3.             Roughly double the weight in pounds and put grams after it.

4.             Cardiomegaly >2 SD, 450-500 gm significant

5.             Cor bovinum > 700gm Normal weights for the entire heart are 270- 350

  1. Describe epicardial surface

1.             Including pericardial fat (abundant, scant),

2.             Petechiae

3.             Adhesions.

  1. Measure the wall thickness of both ventricles and the septum

1.             LV           1-1.5 cm

2.             S              1-1.5 cm

3.             RV           0.3-0.5 cm

  1. Describe the left ventricle

1.             hypertrophy or dilatation

2.             fibrosis (endocardial, epicardial, transmural, location and degree),

3.             infarcts (old or recent, size, location, transmural or subendocardial)

4.            trabeculations

5.             papillary muscles (hypertrophied, thinned, scarred, infracted),

6.             presence of mural thrombus.

  1. Describe the valves

1.             Dimensions

2.             Thickness or lesions

  1. Describe the arteries.  Cut in transverse sections every three-five mm

1.             Left, right, circumflex

2.             Thrombi

3.             Degree of Atherosclerosis, Calcifications

7.             Patence and number of ostia

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

  1. In a non-complicated heart, submit three sections, LV, S, RV
  2. In a heart with lesions, take the above three sections and representative sections of the lesion(s)
  3. Section and submit the coronary arteries.

Coronary artery anatomy

I.

A.            the coronary arteries are the first branches of the aorta

1.             Arise within the aortic sinuses of Valsalva.

2.             There are two arteries, right and left

3.             Three sinuses.

a.             as right coronary, left coronary and non-coronary.

  1. The right coronary artery emerges from the sinus
    1. Antero-superior part of the right arterioventricular groove
    2. Encircles the tricuspid valvar orifice, giving rise to ventricular and atrial branches.
    3. In nine-tenths of individuals, it gives rise to the posterior interventricular artery and in most continues beyond the crux to supply part of the diaphragmatic surface of the left ventricle (right coronary dominance).
  1. The left coronary artery emerges from its sinus into the space between the pulmonary trunk and the left atrial appendage.

1.             After a short course, ≈ one centimeter

2.             Divides into anterior descending

a.             Interventricular groove main left ventricle

3.             Circumflex branches.

a.             Runs round the mitral orifice,

b.             Obtuse ventricular and atrial branches.

c.             In one-tenth of individuals, it is the circumflex artery which gives rise to the posterior interventricular artery (left coronary dominance).

D.            The areas of heart supplied by the three coronary arteries are as follows:

1              Left anterior descending:

a.             Anterior wall of left ventricle

b.             Adjacent area of anterior right ventricle

c.             Anterior two-thirds of the interventricular septum

2.             Left circumflex

a.             Lateral wall of the left ventricle.

3.             Right coronary artery:

a.             Remainder of the right ventricle

b.             posterior region of left ventricle

c.             posterior third of the interventricular septum.

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