Postmortem Analysis of Structural Heart Defects in Fetuses and Children by Magnetic Resonance Imaging

• Editorials
• congenital heart disease
• magnetic resonance imaging

Malformations of the heart are the most complex and common human congenital anomalies. Knowledge gained by autopsy has been essential for understanding congenital heart defects and for devising and perfecting surgical and interventional treatments.¹ New defects continue to be uncovered even in the current era.² Most often the basis of our knowledge of heart defects is careful examination of the gross specimen. Microscopic examination of the heart can be important as well for ascertaining patterns and mechanisms of injury resulting from the natural history of heart defects or their treatment, or from inflammatory diseases (myocarditis) or in-born errors of metabolism (storage diseases).

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Despite the longstanding primacy of autopsy in the study of childhood heart disease, many cases do not undergo expert autopsy analysis. This is, in part, a result of decreasing acceptance of autopsy by families for cultural or religious reasons.³ Autopsy rates have fallen dramatically in the last half century, even at specialized academic medical centers.⁴ This trend accelerated in 1971 when a minimum autopsy rate was eliminated by the Joint Commission on Accreditation of Hospitals (now, the Joint Commission) as a requirement for hospital accreditation. Since then, increasing costs and lack of reimbursement have further diminished autopsy rates, now performed in <10% of hospital deaths in many US academic medical centers and even fewer in community hospitals.⁴ Further, many of the autopsies performed are done by pathologists with insufficient expertise in the analysis of structural heart disease.

Effective, realistic alternatives to autopsy that are acceptable to families and can be performed or overseen by experts are needed to ensure that deceased patients with childhood heart disease are accurately diagnosed. In this regard, a study by Taylor et al⁵ in this issue of Circulation, comparing postmortem cardiovascular MRI …