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Until very recently, examination of the heart was left to the autopsy pathologist. Now, with sophisticated monitoring and instruments, biopsies can be performed upon the living patient. Common reasons for a biopsy include the evaluation of cardiomyopathies, infections, and status of transplanted hearts. These biopsies may be analyzed at both the light and electron microscopic level. Cardiac pathologists who specialize in diagnosing heart biopsies usually reside in major academic or tertiary referral centers.


Acute Coronary Syndrome (Angina, Myocardial Infarction)
Atherosclerosis and Coronary Artery Disease
Cardiac Myxoma (Atrial Myxoma)
Chagas' Disease
Endocarditis, Infective
Endocarditis, Non-Infective (Marantic, Non-bacterial thrombotic, Libman-Sacks)


Gross Appearance and Clinical Variants  
Commonly Used Terms  
Internet Links  


Chiari's network: normal anatomic variant or risk factor for arterial embolic events?

Schneider B, Hofmann T, Justen MH, Meinertz T.

II. Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany.


J Am Coll Cardiol 1995 Jul;26(1):203-10 Abstract quote

OBJECTIVES. This study was performed to assess the prevalence of Chiari's network in patients undergoing transesophageal echocardiography and to determine whether this anomaly is associated with other cardiac lesions or is characterized by typical clinical findings.

BACKGROUND. Chiari's network is a congenital remnant of the right valve of the sinus venosus. It has been found in 1.3% to 4% of autopsy studies and is believed to be of little clinical consequence.

METHODS. Video recordings of 1,436 consecutive adult patients evaluated by transesophageal echocardiography over a 30-month period were reviewed for the presence of Chiari's network. Echocardiographic contrast studies had been performed in all patients with Chiari's network and were compared with those of 160 consecutive patients without a Chiari net, serving as a control group.

RESULTS. Chiari's network was present in 29 of 1,436 patients (prevalence 2%). A frequently associated finding was a patent foramen ovale in 24 (83%) of the 29 patients with Chiari's network versus 44 (28%) of 160 control patients (p < 0.001). Intense right-to-left shunting occurred significantly more often in patients with Chiari's network than in control patients (16 [55%] of 29 patients vs. 19 [12%] of 160 control patients, p < 0.001). Another frequent association was an atrial septal aneurysm in 7 (24%) of 29 patients. The indication for transesophageal echocardiography was a suspected cardiac source of arterial embolism in 24 (83%) of 29 patients with a Chiari net, 13 of whom (54%) had recurrent embolic events. Chiari's network was significantly more common in patients with unexplained arterial embolism than in patients evaluated for other indications (24 [4.6%] of 522 patients vs. 5 [0.5%] of 914 patients, p < 0.001). Potential causes for arterial embolism were present in 9 of the 24 patients with a Chiari net and embolic events (atrial septal aneurysm in 7, cerebrovascular lesion in 2). In 15 (62%) of 24 patients only a patent foramen ovale could be identified. Three patients had deep venous thrombosis and pulmonary embolism at the time of arterial embolism; none had a thrombus detected within the network.

CONCLUSIONS. In patients undergoing transesophageal echocardiography, the prevalence of Chiari's network was 2%, which is consistent with autopsy studies. By maintaining an embryonic right atrial flow pattern into adult life and directing the blood from the inferior vena cava preferentially toward the interatrial septum, Chiari's network may favor persistence of a patent foramen ovale and formation of an atrial septal aneurysm and facilitate paradoxic embolism.

Cystic tumor of the atrioventricular node of the heart appears to be the heart equivalent of the solid cell nests (ultimobranchial rests) of the thyroid.

Cameselle-Teijeiro J, Abdulkader I, Soares P, Alfonsin-Barreiro N, Moldes-Boullosa J, Sobrinho-Simoes M.

Department of Pathology, Clinical University Hospital, University of Santiago de Compostela, Santiago de Compostela, Spain.
Am J Clin Pathol. 2005 Mar;123(3):369-75. Abstract quote  

We studied a series of 10 solid cell nests (SCNs) of the thyroid and a case of cystic tumor of the atrioventricular node (CTAVN) of the heart and reviewed the literature. The CTAVN and SCNs appeared as cystic and/or solid (squamoid) structures mainly composed of polygonal or oval cells (main cells) admixed with occasional clear cells (neuroendocrine and C cells).

Main cells were immunoreactive for simple and stratified epithelial-type cytokeratins, epithelial membrane antigen, carcinoembryonic antigen, carbohydrate antigen 19.9, p63, bcl-2, and galectin-3. Neuroendocrine (and C) cells were positive for simple-type cytokeratins, carcinoembryonic antigen, calcitonin, chromogranin, synaptophysin, and thyroid transcription factor-1.

Our data support the hypothesis that the CTAVN of the heart and the SCNs of the thyroid are identical structures that represent the same lesional process. The assumption that CTAVN is a ultimobranchial heterotopia fits with the known role of cardiac neural crest cells in cardiovascular development.

Malignant primary cardiac tumors. The Cleveland Clinic experience, 1956 to 1986.

Bear PA, Moodie DS.

Department of Cardiology, Cleveland Clinic Foundation 44106.


Chest 1987 Nov;92(5):860-2 Abstract quote

Malignant primary cardiac tumors have uniformly been associated with poor long-term survival.

We reviewed data on 11 patients with such tumors seen between 1956 and 1986. There were five men and six women, with a mean age at presentation of 44 years. Nine (82 percent) of 11 patients presented initially with respiratory symptoms, and 45 percent (five) presented with chest pain. No patient was asymptomatic on initial presentation. Forty-five percent (five) of the patients had elevated jugular venous pressure or a systolic murmur. Cardiomegaly was present in eight (73 percent) of 11 patients. Nine of ten patients had a hemoglobin level less than 12 g/100 ml, and 30 percent (3/10) presented with thrombocytosis. Seventy percent (eight) of the patients underwent surgical biopsy, and in 30 percent (three), surgical excision of the tumor was attempted. Angiosarcoma was the most frequent type of tumor (four patients), followed by malignant fibrous histiocytoma (three patients), mesothelioma (two patients), rhabdomyosarcoma (one patient), and primary lymphoma (one patient). Long-term follow-up data reveals that ten (91 percent) of 11 patients had died, with a mean duration from diagnosis until death of 9.7 months.

Newer pathologic techniques for identification of sarcomas, aggressive surgical resection, and advanced chemotherapy for certain subgroups may contribute to better survival for patients with these tumors in the future. In addition, cardiac transplantation may play an important role in the future for those patients with localized disease.

Cause of Death and Sudden Cardiac Death After Heart Transplantation
An Autopsy Study

Russell T. Alexander, MD, and Charles Steenbergen, MD, PhD


Am J Clin Pathol 2003;119:740-748 Abstract quote

Postmortem findings in 39 patients following cardiac transplantation are presented. Causes of death were right-sided heart failure after transplantation (6 [15%]), infection (5 [13%]), multisystem organ failure (4 [10%]), complications of noncardiac surgery (3 [8%]), acute rejection (3 [8%]), malignant neoplasm (3 [8%]), graft vascular disease (3 [8%]), preservation procurement injury (3 [8%]), cardiac arrhythmia (2 [5%]), other (4 [10%]), and unclear (3 [8%]). Seven patients in medically stable condition died after a sudden cardiac arrest, and these constituted 27% (7/26) of deaths more than 1 month after transplant.

The 7 sudden cardiac arrests were due to graft vascular disease (2 [29%]), acute rejection (2 [29%]), cardiac arrhythmias (2 [29%]), and hyperkalemia during an exacerbation of acute renal failure (1 [14%]). In 3 of the 5 patients who died of sudden cardiac arrest not due to acute rejection, hemodialysis and plasmapheresis were triggers of the event.

Pulmonary hypertensive arteriopathy was associated with early death and right-sided heart failure, and 6 of 8 patients with these changes died perioperatively or postoperatively.

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Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
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DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 5th Edition. McGraw-Hill. 1999.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.

Commonly Used Terms

Bioptome-A device used to obtain an endomyocardial biopsy.

Cardiomyopathy-A group of diseases which lead to hypertrophy (enlargement), dilatation, or restrictive changes within the heart.

Endocardium-This is the inner lining of the heart lining all of the chambers and heart valves.

Epicardium-This is the outermost covering of the heart covering the myocardium.

Extension-Process where necrosis of the heart muscle extends to adjacent viable tissue over a period of days to weeks.   Sometimes referred to as a stuttering infarct.

Myocardium-This is the specialized cardiac muscle.

Pericardium-This is the sac which the heart rests in. There is a small amount of pericardial fluid which bathes the heart. This fluid may become inflammed or infected leading to a pericarditis.

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Surgical Pathology Report
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Last Updated March 15, 2005

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