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Ann Thorac Surg 1997;64:380-383
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

The Autopsy: Still Important in Cardiac Surgery

Division of Cardiac Surgery and Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. This study examined the ability of autopsy to confirm or dispute presumptive cause of death among cardiac surgery patients.

Methods. Autopsy reports were compared with mortality conference notes that were dictated prospectively before autopsy results were available. Between January 1985 and December 1995, there were 600 hospital deaths among 13,029 adult cardiac surgery patients (4.6% mortality). Of these 600 deaths, 147 (24.5%) had postmortem examination.

Results. Annual autopsy rate remained constant over the course of the study. Autopsied patients were younger (60.4 ± 15 versus 66.7 ± 13 years [mean ± standard error of the mean]; p < 0.0001), but their race and sex distributions were similar to deceased patients not having autopsy. Autopsy confirmed clinical presumptive cause of death in 52% (76), disputed clinical diagnosis in 9.5% (14), provided definitive diagnosis in the absence of clinical diagnosis in 13.6% (20), and failed to provide definitive diagnosis in 25% (37). One third of autopsies (39%; 57) provided information that was clinically unrecognized and might have altered therapy and outcome if known premortem. As determined by autopsy, common causes of death were cardiac (27%; 39), unknown (25%; 37), sepsis (14%; 21), stroke (8.8%; 13), cholesterol embolism (4.1%; 6), pulmonary embolism (4.1%; 6), and adult respiratory distress syndrome (4.1%; 6).

Conclusions. Autopsy reveals or confirms cause of death in nearly three quarters of cardiac surgical deaths and provides information that differs significantly from premortem clinical impression more than 20% of the time. As such, the autopsy remains important to quality assurance in cardiac surgical care.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 383.

Improvements in operative and perioperative management of the cardiac surgical patient have decreased mortality and morbidity over the last two decades, but significant risk still attends cardiac surgical procedures. Published hospital mortality rates for adult cardiac surgical procedures generally range from 1% to 10% depending on the nature of the procedure, experience of the center, patient age, and patient comorbidity [1–6]. Accurate determination of cause of death plays an obvious role in improving quality of care, albeit in retrospective fashion, by identifying technical errors, suggesting modification of postoperative management strategies, and identifying high-risk patients.

For decades, the autopsy has been the gold standard for determination of cause of hospital deaths. However, in recent years, autopsy rates have fallen in most hospitals, presumably due to several factors: fear of litigation if autopsy reveals error in diagnosis or therapy, cost, relaxation of mandated percentages of deaths requiring autopsy, and the misconception that current diagnostic studies are so accurate that autopsies are unnecessary [7]. This trend threatens to remove an important component of surgical care.

Herein, we sought to evaluate the autopsy in adult cardiac surgery patients to ascertain its value in providing supportive or contradictory findings compared with premortem clinical impression.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Cardiac surgery mortality and morbidity conferences are held monthly at our institution. Clinical summaries of case mortalities are prepared for conference based on clinical data obtained before the autopsy report. We evaluated 147 consecutive autopsies from January 1985 to December 1995. The postmortem reports were analyzed for cause of death and associated pathologic findings. Results were compared with mortality conference notes, and agreement or contradiction was noted. Several patient- and procedure-related variables were also submitted to univariate analysis to identify factors that might predict autopsy with significant new findings. Cardiac deaths were defined as those attributable to low output syndrome, acute myocardial infarction, or mechanical failure (eg, postinfarct ventricular septal defect, ruptured papillary muscle).

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Between January 1985 and December 1995, there were 600 hospital patient deaths among 13,029 adult cardiac surgery patients (4.6% mortality). Of these 600 patients, 147 (24.5%) underwent postmortem examination. The annual autopsy rate remained constant over the course of the study. Autopsied patients were younger (60.4 ± 15 versus 66.7 ± 13 years; p < 0.0001) than those not undergoing autopsy. Sixty-four percent were male. Race distribution was white, 85%; black, 14%; and Asian, 1.4%. Race and sex distributions were similar between the autopsy and nonautopsy groups. Mortality occurred at a mean of 22 days after operation. Operative procedures for the autopsy patients are shown in Table 1.

There were 20 patients in whom autopsy revealed a cause of death not suspected clinically. Eight had cardiac causes, 4 had pulmonary embolism, 3 had sepsis, 2 suffered from technical error, and 1 (each) succumbed to adult respiratory distress syndrome, cholesterol embolism, and gastrointestinal bleeding.

Information that was clinically unrecognized and might have altered therapy and long-term outcome if known premortem was found in 57 patients (39%). These diagnoses were not necessarily the primary cause of death (see Table 2). Commonly, occult malignancies were discovered ("other" in Table 2): prostate cancer (2 patients), islet cell tumor (2 patients), metastatic carcinoid (2 patients), renal cell neoplasm (1 patient), metastatic adenocarcinoma and lymphoma (2 patients), rectal carcinoma (1 patient), lymphoproliferative disorder (1 patient), and multiple spinal cord schwannomas (1 patient). Specific cardiac diagnoses included idiopathic hypertrophic subaortic stenosis in 2 patients, cardiac toxoplasmosis in 1, and ascending aortic dissection in 1. Two cases of pulmonary aspergillosis were diagnosed.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Traditionally, autopsy has served as the gold standard for clinical diagnosis. The extent to which it has agreed or disagreed with premortem clinical diagnosis has been studied in various clinical settings. High agreement (>80%) has been documented in neonates and infants in whom fetal or early infancy ultrasound has identified lesions [8], in children with sudden infant death syndrome [9], in neurologic conditions such as subarachnoid hemorrhage, cerebral hemorrhage, and cerebral infarction [10], and in myocardial infarction [11]. In contrast, poor agreement has been observed in the diagnosis of pulmonary embolism, gastrointestinal bleeding, and the diagnosis of malignancy [11–14]. In most studies, the concordance rate is 50% to 75% [15–20], similar to the 52% observed in the current study. In a study of noncardiac postoperative deaths, 40% of autopsies revealed major discrepancies between clinical and postmortem diagnoses [21]. These studies show that despite modern diagnostic imaging and growing experience in the care of complex surgical patients, there persists significant clinical error and misinformation.

Autopsy is probably most valuable when results are at odds with the clinical diagnosis. In the case of technical error, it provides unmistakable evidence that may lead to prevention of repeat error. In overlooked diagnoses, it may instruct the caregiver and provide an important lesson of experience. This study failed to identify patient, procedure, or diagnostic subgroups for which autopsy was either superfluous or particularly rewarding, but it should be noted that certain types of cardiac death such as arrhythmia are difficult to diagnose by postmortem examination, and may be underrepresented in this study. Furthermore, it should be acknowledged that the quality of postmortem examination may vary. In some institutions, it is unfortunately relegated to the most junior member of the pathology team, with little or no contribution from the surgical team. The latter situation is unfortunate when the surgical repair is unusual or complex, and the presence of the surgeon at autopsy may facilitate discovery.

Accurate diagnosis is the cornerstone of excellence in clinical care. In our study, 24.5% of deaths came to autopsy. Although this rate is lower than the 36% to 49% rate in Scandinavian countries, it is higher than the rate in the United States of 12% [7]. Our autopsies revealed or confirmed definitive cause of death in 75%; furthermore, in one third of these patients, the clinical diagnosis of cause of death was unknown or was erroneous. Thus, we believe the autopsy can and should remain an important source of clinical feedback that is critical to quality assurance in cardiac surgical care.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-Third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7–9, 1996.

Address reprint requests to Dr Cameron, Division of Cardiac Surgery, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287-4618 (e-mail: dcameron{at}welchlink.welch.jhu.edu).

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kenton J. Zehr John R. Liddicoat Jorge D. Salazar A. Marc Gillinov Duke E. Cameron Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zehr, K. J. Articles by Cameron, D. E. Search for Related Content PubMed PubMed Citation Articles by Zehr, K. J. Articles by Cameron, D. E. Related Collections Related Article