Autopsy in the Era of Advanced Cardiovascular Imaging

Cristina Basso; James R. Stone


Eur Heart J. 2022;43(26):2461-2468. 

In This Article

Abstract and Introduction


Graphical Abstract: Clinical role of autopsy in patients who die unexpectedly or of known cardiac disease: identification of cardiac disease; confirmation of cardiac disease; and assessment of treatment and disease progression. Top: myocardial disease. Stage 1: Asymptomatic, subclinical (not detectable by current imaging, but detectable at autopsy). Stage 2: Asymptomatic, mildly dilated (detectable by imaging and at autopsy). Stage 3: Symptomatic, dilated (detectable by imaging, confirmed at autopsy). Stage 4: Symptomatic, dilated, post-treatment (assessment of therapy, verification of diagnosis). Bottom: coronary artery disease. Stage 1: Asymptomatic, mild atherosclerosis, complicated by acute thrombosis. Stage 2: Asymptomatic, moderate atherosclerosis, complicated by thrombosis. Stage 3: Symptomatic, severe atherosclerosis. Stage 4: Symptomatic, atherosclerosis post treatment (stent), complicated by thrombosis.

Historically, autopsy contributed to our current knowledge of cardiovascular anatomy, physiology, and pathology. Major advances in the understanding of cardiovascular diseases, including atherosclerosis and coronary artery disease, congenital heart diseases, and cardiomyopathies, were possible through autopsy investigations and clinicopathological correlations. In this review, the importance of performing clinical autopsies in people dying from cardiovascular disease, even in the era of advanced cardiovascular imaging is addressed. Autopsies are most helpful in the setting of sudden unexpected deaths, particularly when advanced cardiovascular imaging has not been performed. In this setting, the autopsy is often the only chance to make the correct diagnosis. In previously symptomatic patients who had undergone advanced cardiovascular imaging, autopsies still play many roles. Post-mortem examinations are important for furthering the understanding of key issues related to the underlying diseases. Autopsy can help to increase the knowledge of the sensitivity and specificity of advanced cardiovascular imaging modalities. Autopsies are particularly important to gain insights into both the natural history of cardiovascular diseases as well as less common presentations and therapeutic complications. Finally, autopsies are a key tool to quickly understand the cardiac pathology of new disorders, as emphasized during the recent coronavirus disease 2019 pandemic.


There are many benefits from performing clinical autopsies. Autopsies are important for the education of trainees and practitioners. Autopsies also enable identification of new or re-emerging diseases. Autopsies allow for the acquisition of accurate statistics relating to diseases and deaths, and for the surveillance for adverse effects of drugs, devices, and procedures. Thus, they can be invaluable for hospital quality assurance assessments of diagnostic and therapeutic procedures. Furthermore, autopsies allow for the identification of diseases of clinical relevance to the public or relatives, and for the accurate determination of the cause of death in research studies and clinical trials.[1–4] Last but not least, autopsies have the ability to improve the completeness and reliability of death certificates, which can impact both families and also public health strategies.

Despite all of the above, the autopsy rate steadily declined in the second half of the last century to fall below 10% in the USA.[2,5] As far as Europe is concerned, a 2015 survey of the European Society of Pathology working group of Autopsy Pathology regarding autopsy practice demonstrated a lack of reliable statistics on medical autopsy activity, with no available data from several countries such as France and Germany and very low national rates in other countries such as Spain, Portugal, and Italy, where teaching and non-teaching hospitals were analysed together.[6]

Many factors may have contributed to this negative trend, such as the elimination of the minimum autopsy rate requirements for accreditation of healthcare organizations. Other factors include an apparent growing lack of clinician awareness about the value of autopsy and the autopsy process itself, the fear of potential legal implications for the treating medical team, and the costs.[1–4,7,8] Although the analysis of the various determinants of declining autopsy rates is beyond the scope of this article, we would like to draw attention to the attitude of clinicians and pathologists regarding autopsies.[1] Many studies suggest that the decline in hospital autopsy rates is due more to the clinicians' unwillingness to seek consent for an autopsy than to the relatives' unwillingness to grant consent. Unwillingness to seek consent for an autopsy can result from a lack of time and clinical pressures, the feeling that the advances in diagnostic imaging and laboratory testing have reduced the value of autopsy, and the assumption that the family is opposed to an autopsy. The attitude of pathologists is equally important, since many pathologists with time commitments in research, teaching, and surgical pathology consider autopsies to be too time-consuming and of little clinical value. The unwillingness of treating clinicians to attend the autopsy or in some instances even discuss the case gives rise to further misconceptions about the clinical value of autopsies. Building a new enthusiasm for autopsy, with an increase in hospital autopsy rates, requires a close interaction between clinicians and pathologists, who should discuss the case before and after the autopsy, possibly having the clinicians attending the autopsy itself. The goal is to provide high quality, pathophysiology-based autopsy reports that are coherent with clinical findings, answering to the clinicians' questions in a timely manner, rather than a list of abstract anatomical findings. A preliminary report should be distributed soon after the autopsy, and the final report, including microscopic examination, should be finalized in a timely fashion, possibly within 30 days, since delayed reports are less useful for the requesting physicians. When feasible, deaths should be discussed at a multi-disciplinary morbidity and mortality conference where all of the physicians involved in the patient's care can attend. This approach would improve clinicians' perception of the value of autopsy.

The authors of this article work at the Medical School Hospital, University of Padua and at the Massachusetts General Hospital, Harvard Medical School, respectively. While Walter Cannon and Richard Cabot inaugurated the clinicopathological conference (CPC) at Harvard Medical School in the early twentieth century, the method of clinicopathological correlation was introduced by Giovanni Battista Morgagni at the University of Padua in the eighteenth century.[9,10] The autopsy and CPC are still in use in many academic hospitals, as our own, to teach undergraduate medical students, pathology residents and clinical residents, but also for post-graduate continuing medical education.

Why an article about autopsy and cardiovascular diseases in 2022? There is no doubt that autopsy historically contributed to our current knowledge of cardiovascular anatomy, physiology, and pathology. Major advances in the understanding of cardiovascular diseases, including atherosclerosis and coronary artery disease, congenital heart diseases, and cardiomyopathies, were possible through autopsy investigation and clinicopathological correlations. In this article, we will address some of the reasons to ask for clinical autopsies in people dying from cardiovascular disease (Graphical abstract).