96. Jahrestagung der Deutschen Gesellschaft für Pathologie e. V ...

Abstracts
FR-P-165
Potential complications of aortic valve implantation via a transfemoral
artery catheter: an autopsy perspective
H . Löser 1 , H .P . Dienes 1 , J . Fries 1
1 University of Cologne, Institute of Pathology, Köln
Aims. Degenerative or post-endocarditic destruction of aortic valves
with secondary left ventricular hypertension and subsequent cardiac insufficiency
is seen more frequently in patients with increasing age. The
instable health of many of these patients does not permit a removal of
the diseased valve in an open surgical procedure. Instead, an aortic valve
implantation is achieved via either a transapical access or a transfemoral
artery catheter. In Cologne, the catheter carrying a ballon-expandable
stent with a valve of bovine pericardium (Edwards-SAPIEN System) has
been used for the last 3 years. While in the majority of cases this procedure
was completed successfully, we encountered several autopsy cases,
in which unforeseen complications occurred directly related to this type
of valve replacement.
Methods. All patients were in the age range of 65 to 80 years. Preclinical
evaluation had indicated that a conventional surgical approach either by
transsternal access or by intercostal/apical access would not be tolerated
by the patient and an aortic valve implantation via transfemoral catheter
using the Edwards-SAPIEN Systems was performed. Patients had died
within hours of valve implantation and a full body autopsy was performed
in each case once appropriate consent was given.
Results. The observed complications had been: 1. irreversible compression
of implanted valve due to cardiac resuscitation, 2. implantation of a
small diameter valve not properly anchored due to excessive calcification
with paravalvular leak, 3. loss of valve being dislodged before the aortic
isthmus, 4. tilted implantation of valve due to calcifications of the aortic
ring with pressure necrosis of aortic wall and paraaortic bleed, 5. transmural
aortic rupture due to a calcified ring of the aortic valve after balloon
dilatation with intramyocardial/pericardial bleeding leading to coronary
compression with secondary hemorrhagic infarction.
Conclusions. In all cases the preoperative lack of information of the degree
of calcification of the aortic valve leaflets was a common denominator
for postoperative complications. Future improvements of three
dimensional imaging appear necessary to increase the chance of preventing
such complications. Until then, autopsy analysis of complications
may be the only way to detect potential weaknesses of an otherwise lifesaving,
but high risk procedure.
FR-P-166
Situs inversus totalis of twins: an autopsy case report
C . Tóth1 , M . Jäckel2 , K . Bartók2 1University Hospital Heidelberg, Institute of Pathology, Heidelberg,
2Military Hospital, Budapest, Hungary
Aims. Situs inversus totalis is a rare congenital abnormality resulting in
visceral malrotation of the internal organs leading to left-right asymmetry.
In certain cases it is associated with clinically defined syndromes e.g.
Kartagener’s syndrome. In the case presented after 9 attempts of in vitro
fertilization and reduction (from three embryos to two embryos) in the
20th gestation week cesarean section was performed because of acute
purulent chorioamnitis with spontaneous rupture of membranes.
Methods. The medical history of the mother included primary sterility
with 9-times in vitro fertilization with F II 20210 heterozigosity and
MFHFR polymorphism with homozigosity. Further, factor Xa thrombophily
was also in her family diagnosed. After the operation the placenta
and two fetus were macroscopically and histologically examined.
Results. Placenta: 390 g with intact two amnoitic sacs with two umbilical
cords with central origin and three blood vessels (2 arteries and 1 vein).
The cut surface of the placenta shows some grayish areals, the rest is normal.
Fetus A: 304 g, 22 cm long male fetus. Ventricular and ependymal
bleeding in the 4th ventricle. In the thorax the heart apex lies on the
136 | Der Pathologe · Supplement 1 · 2012
right side, the left lung consists of 3 lobes, the right one consists of 2.
The cut heart and the great blood vessels run according to a total situs
inversus situation. In the abdomen after removing a blood clot normal
developed organs with total malrotation can be found. The pelvis organs
macroscopically show no abnormality. Fetus B is a 297 g, 23 cm female
fetus with some petechial skin bleedings. The central nervous system has
no abnormalities. The thoracal and abdominal organs show the same
malrotational changes as described above at fetus A. The changes were
photographically documented.
Conclusions. The cause of spontaneous abortion was an acute purulent
chorioamnitis due to a probably ascending infection which caused the
spontaneous rupture of the membrane. The autopsy cannot explore the
cause of infection. Both of the autopsied fetus showed the rare malrotation
changes, the situs inversus totalis without any other developmental
disturbances. In the daily autopsy practice we need to know about these
rare changes which are important not only in fetopathology but in anatomical
pathology as well.
FR-P-167
Analysis and appraisal of the clinical autopsy results of a surgically
oriented cardiac center in terms of quality assurance
J . Grüning1 , R . Meyer1 , M . Dietel2 , R . Hetzer1 1 2 Deutsches Herzzentrum Berlin, Berlin, Charité, Humboldt-University in
Berlin/ Institute for Anatomic Pathology, Berlin
Aims. We aimed to analyze the quality of clinicopathologic documentation
and communication. Concentrating on the following two questions:
1.) How valuable are the medical documentation of the inspection of the
corpse (post-mortem/clinical autopsy) and the content of the autopsy
requests and are they adequate for a qualified-autopsy? 2.) Are the autopsy
findings and examinations in line with the quality requirements
of a cardiac center?
Methods. Between 2000 and 2009 an average autopsy rate of 37% of all
decedents (range, 28% to 45%) was reached at our institute. During that
time 1063 decedents underwent autopsy. In accordance with the above
objectives the following were analyzed and assessed: documentation of
the inspection of the corpse (causal chain of the causes of death; personal
data; formalities), content of the autopsy requests (clinical procedures),
autopsy reports (date of autopsy; date of compilation of the autopsy report
and granting of access for the clinician have been recorded). The clinical
and autopsied underlying diseases and causes of death were coded
in accordance with ICD 10.
Results. It was evaluated as positive that documentation of the inspection
of the corpse, content of the autopsy requests and the autopsy reports
themselves are in correct form. Also positive is, that the recorded autopsy
results are discussed during weekly medical meetings at the institution.
Regrettably, however, the pathologists do not participate in these
meetings. The fact that the majority of autopsy reports do not reach the
clinician until after 30 days is a serious problem precluding their prompt
evaluation and discussion. The clinicians and pathologists need to change
for the better communication in relation to analyzing and assessing
the autopsies. There have been discrepancies between the clinically determined
causes of death and the autopsy causes of death. In particular
the clinically determined cause of death of “sepsis” needs to be discussed.
The preparation of the autopsy reports has no real influence on the
hospital’s cost accounting (DRG).
Conclusions. It becomes apparent that the autopsy report constitutes an
effective tool for quality assurance. The weekly medical meeting is a suitable
forum to look at quality assurance issues. The quantity and quality
of the communication between clinician and pathologist leave room for
improvement and strengthening.