Stanley L. Robbins

The Value of the Autopsy in Three Medical Eras

To determine whether advances in diagnostic procedures have reduced the value of autopsies, we analyzed 100 randomly selected autopsies from each of the academic years 1960, 1970, and 1980 at one university teaching hospital. In all three eras about 10 per cent of the autopsies revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival; another 12 per cent showed a clinically missed major diagnosis for which treatment would not have been changed. Among 1980 autopsies, renal disease and pulmonary embolus were less common causes of death than before, but systemic bacterial, viral, and fungal infections increased significantly and were missed clinically 24 per cent of the time. The introduction of radionuclide scans, ultrasound, and computerized tomography as diagnostic procedures did not reduce the use of conventional tests in patients who subsequently died and were studied by autopsy. Over-reliance on these new procedures occasionally contributed directly to missed major diagnoses. We conclude that advances in diagnostic technology have not reduced the value of the autopsy, and that a goal-directed autopsy remains a vital component in the assurance of good medical care.

Cardiac Rupture during Myocardial Infarction A Review of 44 Cases

Forty-four cases of myocardial infarction with cardiac rupture, 88 cases of unruptured myocardial infarction, and 88 cases without myocardial infarction were studied retrospectively. The incidence of cardiac rupture in cases with acute myocardial infarction alone was 5.5% while in hearts having both healed and acute myocardial infarction the incidence was 2.3%. One instance of cardiac rupture was encountered in a heart having only a healed myocardial infarction with subsequent aneurysmal dilation of the healed infarct. Although females represented only 37% of the population having acute myocardial infarction in this institution, they accounted for 55% of the cases of cardiac rupture. On the average the hearts which ruptured following myocardial infarction were lighter and thinner than in the control group of patients having infarction without rupture. Among the clinical correlates possibly associated with postinfarction rupture the most significant finding in the present study is the presence of postinfarction hypertension. In the group of cases with cardiac rupture this was present in 40% while in the control group not having suffered cardiac rupture the comparable figure was 14%. A history of diabetes was found in 18% of the cases of myocardial infarction not having suffered cardiac rupture. A similar history was found in only 9% of the cases having a postinfarction cardiac rupture. This latter incidence is identical with the frequency of diabetes mellitus in the general autopsy population. There is a suggestion that early and severe atherosclerosis may cause earlier heart disease and when infarction occurs provide some protection against rupture. Of interest among the 44 cases of cardiac rupture, none of the patients had cirrhosis, in striking contrast to the 11% incidence of this condition in our general autopsy population.

Capacity of Human Coronary Arteries A Postmortem Study

A postmortem study of the capacity of the coronary arteries of 100 human hearts is presented. The volume of Schlesingers barium sulfate-gelatin injection mass entering the coronary arterial tree under standard conditions was taken as a measure of its capacity. The factors analyzed include the weight of the heart in the normal and diseased state, the cross-sectional dimensions of the main coronary arteries near their origins, and the sex, age, and nutrition of the subjects.

Radioautographic studies in experimental myocardial infarction: Profiles of ischemic blood flow and quantification of infarct size in relation to magnitude of ischemic zone

Abstract A radioautographic method was adapted to assess regional blood flow in focal myocardial infarction produced experimentally in dogs with ligation of a branch of the left circumflex artery. Twenty-four hours later, the dogs were given an infusion of 1 millicurie of 14 C-antlpyrine and killed. Radloautograms were prepared from 20 μ full thickness sections Of the infarcted segment of each left ventricle. Adjacent tissue sections were also prepared for histopathologic study and comparison. Photodensltometric scanning of radioautograms in transverse and transmural planes permitted quantification of regional blood flow, measurement of dimensions of the zones of blood flow reduction and construction of profiles of Ischemic blood flow within a cubic reference system. Thus, transverse plane scans showed symmetric profiles of decreasing blood flow from each normal margin (mean ± standard error of the mean 0.75 ± 0.11 ml / g per min) to the center of the Infarct (mean 0.08 ± 0.02 ml / g per min or 11.7 ± 3.5 percent of normal flow); transmural plane scans showed an asymmetric profile of decreasing blood flow from the epicardlum (mean 0.36 ± 0.06 ml / g per min) to the center of the infarct and a subsequent increase to 0.22 ± 0.03 ml / g per min near the endocardial surface. From a comparative analysis of radioautograms with corresponding adjacent histologie sections we determined that (1) myocardial necrosis was first evident at the point of blood flow reduction that averaged 45.2 ± 3.2 percent of normal values; (2) a border zone of intermediate flow reduction where cell viability was maintained 24 hours after infarction averaged 4.5 ± 0.5 mm and encompassed 30.4 ± 3.0 percent of total ischemic zone width; and (3) on the basis of various geometric models, the size of the myocardial infarct in these experiments was approximately 40 percent of that of the ischemic zone.

Relation of the degree of coronary-artery disease and of myocardial infarctions to cardiac hypertrophy and chronic congestive heart failure.

HEART disease and heart failure in aging persons are usually assumed to be due to coronary arteriosclerosis (arteriosclerotic heart disease, ischemic heart disease) if other identifiable causes of ...

Postmortem angiographic studies on the coronary arterial circulation

Abstract Four hundred and seventy adult human hearts from patients 13 to 96 years of age were studied angiographically using barium sulfate-gelatin injected at 200 mm. Hg for 5 minutes (modified Schlesinger method). In 40 hearts, some coronary arteries were ligated and transected before injection; in another 430 hearts, no ligations were made. Intercoronary arterial anastomoses were detected in two ways: (1) by stereoangiography, and (2) by applying Schlesingers criteria (i.e., anastomoses are considered to be present if dissected in toto, or if mass appears beyond a coronary obstruction, or if mass injected into one coronary enters another). By Schlesingers criteria, anastomoses were present in almost all hearts with coronary occlusion or ligation, and absent in most of the other hearts comprising the bulk of the series. Cardiomegaly, valve deformity, cor pulmonale, and anemia did not increase the incidence of anastomoses detected. Stereoangiography disclosed macroscopic anastomoses in all hearts with natural or artificial occlusions, and in many hearts which fulfilled none of Schlesingers criteria. These anastomoses connected major coronary divisions, or different branches of the same division, or different segments of the same branch. Anastomoses in hearts without occlusive coronary artery disease were small, few, and spotty in distribution. Those associated with old occlusions were enlarged, numerous, and strategically concentrated to bypass occlusions. This study suggests that: (1) intercoronary arterial anastomoses exist in most adult human hearts; (2) the demonstration of anastomoses by Schlesingers method is mechanically favored by coronary occlusions, natural or otherwise; (3) current controversy in regard to the incidence of intercoronary arterial anastomoses in normal human hearts stems from the error of equating absence of anastomoses with inability to detect them.Abstract Four hundred and seventy adult human hearts from patients 13 to 96 years of age were studied angiographically using barium sulfate-gelatin injected at 200 mm. Hg for 5 minutes (modified Schlesinger method). In 40 hearts, some coronary arteries were ligated and transected before injection; in another 430 hearts, no ligations were made. Intercoronary arterial anastomoses were detected in two ways: (1) by stereoangiography, and (2) by applying Schlesingers criteria (i.e., anastomoses are considered to be present if dissected in toto, or if mass appears beyond a coronary obstruction, or if mass injected into one coronary enters another). By Schlesingers criteria, anastomoses were present in almost all hearts with coronary occlusion or ligation, and absent in most of the other hearts comprising the bulk of the series. Cardiomegaly, valve deformity, cor pulmonale, and anemia did not increase the incidence of anastomoses detected. Stereoangiography disclosed macroscopic anastomoses in all hearts with natural or artificial occlusions, and in many hearts which fulfilled none of Schlesingers criteria. These anastomoses connected major coronary divisions, or different branches of the same division, or different segments of the same branch. Anastomoses in hearts without occlusive coronary artery disease were small, few, and spotty in distribution. Those associated with old occlusions were enlarged, numerous, and strategically concentrated to bypass occlusions. This study suggests that: (1) intercoronary arterial anastomoses exist in most adult human hearts; (2) the demonstration of anastomoses by Schlesingers method is mechanically favored by coronary occlusions, natural or otherwise; (3) current controversy in regard to the incidence of intercoronary arterial anastomoses in normal human hearts stems from the error of equating absence of anastomoses with inability to detect them.

The descending septal artery in human, porcine, equine, ovine, bovine, and canine hearts: A postmortem angiographic study☆

Abstract An accessory artery which helps supply the cardiac interventricular septum in man and some animal species is described. It arises from the proximal part of the right coronary artery or directly from the aorta, descends through the superior septal border, and ramifies in the septum. This vessel is here called the “descending septal artery.” It was demonstrated in 12 per cent of the 427 human, all of the 15 bovine, 40 of the 60 porcine, 8 of the 20 ovine, 1 of the 4 equine, and none of the 31 canine hearts studied by Schlesingers technique and unrolled by the method of Rodriguez and Reiner. Its development varied within and between species. In the human species, it occurred in normal and diseased hearts. Its caliber ranged from 0.3 to 1.6 mm. Its incidence was unrelated to race, age, or coronary pattern, was higher in males than in females, and increased twofold in the presence of occlusions elsewhere in the coronary arterial tree. The descending septal artery was found free of occlusive disease. Like the conus artery, this vessel appears to serve as a route for anastomotic blood flow to other vessels of the heart when these are narrowed or occluded. The amount of myocardial damage resulting from coronary narrowing or occlusion may, in part, be determined by the presence or absence of the descending septal artery.

Problems in the quantitation of coronary arteriosclerosis

Abstract The present study tends to show the not inconsiderable difficulties inherent in both measurements and judgments of arterial stenosis in the coronary arteries. Clearly, longitudinally opened arteries are the least suitable of the three types of media for this evaluation; arteries showed a high degree of variance 45 per cent of the time, compared to 10 per cent for angiograms and 25 per cent for casts. Angiograms tend to produce consistent results, and in 90 per cent of the readings a variance of not greatethan 1+ was found. However, this consistence was at the expense of failing to reflect small changes in vascular lumens. Thus angiograms give lower readings of severity of stenosis than casts. In contrast, arteries and casts show a 1+ variance 30 and 50 per cent, respectively, in part because casts more completely reflect the complexity of the deformities induced by atheromatous lesions and thus complicate the issuin judging the segment and severity of stenosis. Possibly better consistency might be achieved by multiple observers using all three media simultaneously.

Demonstration of Intercoronary Anastomoses in Human Hearts with a Low Viscosity Perfusion Mass

The coronary arteries of 120 nonselected human hearts were perfused with a low viscosity radiopaque medium comprising essentially a suspension of barium sulfate in agar. In each of four groups of 30 hearts, one major artery was perfused, that is, right coronary, left main coronary, left anterior descending trunk, or left circumflex trunk. Anastomoses were detected either by cross-filling of unperfused vessels or by direct stereoscopic visualization. Anastomoses were demonstrable in 84% of the entire series, but the frequency varied between the four groups (right coronary 93%, left main coronary 90%, left anterior descending 90% and left circumflex 60%). The presence of stenotic disease did not seem to affect the frequency of demonstrable stenosis since 84% of the hearts virtually free of arterial disease contained recognizable stenoses as compared with 92% of hearts with a stenosis of more than 50% of the arterial lumen. Neither did age, hypertension or left ventricular hypertrophy produce any alteration in the frequency rates. There were seven hearts with occlusive disease; only five contained demonstrable anastomoses. The 19 hearts in the total series in which anastomoses could not be found were derived from patients, some of advanced age, some young, some having occlusive arterial disease and some hypertension.The results of the study suggest that anastomoses are present in most hearts unrelated to clinical disease. They may be increased in size or number by factors that affect coronary hemodynamics, but the present study does not investigate this possibility.

REPORT OF COMMITEE ON GRADING LESIONS, COUNCIL ON ARTERIOSCLEROSIS, AMERICAN HEART ASSOCIATION Grading Stenosis in the Right Coronary Artery

The American Heart Associations Committee on Grading Lesions of the Council on Arteriosclerosis has devised a method of grading the severity of atherosclerosis in human coronary arteries and aortas. The method uses two series of color photographs of arteries arranged in increasing severity of atherosclerosis. The Committee tested the method for inter-observer reproducibility by exhibiting the panel at two national scientific conventions and inviting visitors to grade a set of arteries with the panel. The test demonstrated a reasonable degree of inter-observer reproducibility despite a wide range of experience and disciplinary background. Inter-observer variability decreases with increasing experience in working with atherosclerotic lesions. Training graders who participate in a study may reduce inter-observer bias. For populations with predominantly less or predominantly more atherosclerosis, the investigator should construct special panels with different ranges of severity. The Committee revised the pan...