Post mortem examinations after cardiac surgery

Abstract

A t present in England and Wales just over 20% of all deaths are followed by a post mortem examination, almost all on the instructions of a coroner. In contrast, in Scotland and Northern Ireland the rates are below 10%. In a wider context overall post mortem rates in the provinces of Canada vary between 5-9% and are probably much lower in France and Germany. The reasons for this variation are unknown. Remarkably there has been no national audit of the indications for, or value of, autopsy examination. In this review we consider: c why autopsies should be performed after cardiac surgery c who should perform these autopsies and how they should be reported c what has been learnt from post mortem examinations performed on patients dying after cardiac surgery c what the role of these autopsies is in the future. POST MORTEM EXAMINATION AFTER SURGERY cPathologists frequently refer to the many published studies which have shown that important new information is detected in autopsies performed in patients dying in hospital.1 At least two have shown that the rate of unexpected findings has not altered significantly over several decades. Methods have been developed to categorise the degree of concordance between pre-mortem clinical diagnoses and post mortem findings.2 A recent meta-analysis identified discrepancies in 10-20.6% of post mortem examinations where the patient would potentially have survived if the correct diagnosis had been known in life. 4 Although most of these studies have included patients dying after surgery, there have been few that specifically studied the value of post mortem examination after surgery. A retrospective study from Connecticut studied the clinical records and post mortem reports of 150 patients who died in a surgical intensive care unit. There was full agreement in only 58% of cases. The longer the patient was in the unit the greater the chance was of an unexpected finding. Infection was the most common undiagnosed condition, especially in patients who had received a transplant. 6 Impressed by these findings, we made a similar audit of 92 patients dying in our hospital after surgery in 2002 who had an autopsy. We found full agreement in 65%, a major disagreement in 20% and less important discrepancies in 15% of cases. Infection, pulmonary thromboembolism and ischaemic heart disease were the most important conditions diagnosed at post mortem examination. Important discrepancies were identified in 33% of orthopaedic procedures, 31% of neurosurgical, 27% of general surgical operations, but only 5.7% of cardiac operations.

Preoperative intra-aortic balloon pump in high-risk coronary bypass grafting

“…2 The majority of deaths following cardiac surgery are due to cardiac causes, and there is some evidence from randomized controlled trials and meta-analyses that prophylactic intra-aortic balloon pumping (IABP) may reduce mortality in a selected group of high-risk patients undergoing CABG. [3][4][5][6][7][8][9] Despite these findings, prophylactic IABP is employed variably and in only a small subset of those at high risk. [10][11][12][13][14][15] Limitations to widespread use include concerns over the external validity of some studies, the invasive nature of the therapy, the risk of associated complications, and the preference to place an IABP only in the subset of high-risk patients in whom it becomes therapeutically indicated during weaning from bypass or postoperatively.…”

Forensic Sciences and Growth of Cardiology

“…He traced the elaborate network of the blood vessels and accurately described the anatomy of the heart [1]. The significance of the approach of these two path finders is evident from the observations that over centuries, there has been no significant decrease in the rate of unexpected findings detected in either medico-legal autopsies or postmortem studies on patients dying from natural causes in hospitals [2,3].…”