Original Article

Spectrum of histopathological lesions of heart: An autopsy

study at tertiary care center
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Varsha Pandey, Vishal Kulkarni1, Vanita Bhaskar, Veenapani Mire2

Department of Pathology, Pt. Jawahar Lal Nehru Memorial Medical College, Raipur, 1Department of Pathology, Goverment Medical College
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Ambikapur, Ambikapur, 2Department of Pathology, B.D.M. Medical College (GMC) Korba, Korba, Chhattisgarh, India

Abstract Background: There has been a notable rise in cardiac-related fatalities globally, especially in the last five decades.
In India, ischemic heart disease has become prevalent, affecting roughly 10% of the population. For forensic
specialists, establishing the cause of death in individuals previously in good health can be complex. Autopsies
are crucial in evaluating the underlying factors responsible for such deaths. This research seeks to identify and
scrutinize a wide range of histopathological heart abnormalities that significantly influence the determination of
the cause of death.
Materials and Methods: This study was conducted in the Department of Pathology from January 2020 to
December 2020. During this period, we received a total of 209 whole heart specimens. Of these, 208 specimens
underwent comprehensive examinations, including macroscopic and microscopic observations.
Results: Out of the 208 cases examined, 94 showed evidence of both early and advanced atherosclerosis,
whereas 65 showed early and late signs of myocardial infarction. Myocardial hypertrophy was evident in 29
patients. Isolated instances of myocarditis and pericarditis were observed in one case each. Fatty streaks were
identified in 32 cases; three showed red blood cells with sickle cell morphology. Heart rupture was detected in
one case, and another revealed metastasis from a poorly differentiated tumor. Notably, in 90 cases, the cause
of death remained undetermined despite thorough macroscopic and microscopic autopsies.
Conclusion: The primary reason for cardiovascular fatalities is atherosclerosis-related myocardial infarction.

Keywords: Autopsy, heart, histopathology

Address for correspondence: Dr. Varsha Pandey, Department of Pathology, Pt. Jawahar Lal Nehru Memorial Medical College, Raipur 492001,
Chhattisgarh, India.
E-mail: drpandeyvarsha@gmail.com

INTRODUCTION cellular level, which ultimately leads to death. Autopsy

A meticulously performed autopsy is one of the essential
and valuable tools to establish the diagnosis and to know
the cause of death. It provides changes occurring at the
Received: 16-05-2023
Accepted: 08-09-2023
Published: 28-09-2023
of a heart specimen is a mandatory part of medico-legal
examination, as cardiovascular deaths show an increase in
trends, especially in the last five decades. India has shown
an increase in cardiac deaths in the previous 60 years by
1% to 9%–10% in the urban population and comparatively
lower in the rural population of <1% to 4%–6%.[1]

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DOI: How to cite this article: Pandey V, Kulkarni V, Bhaskar V, Mire V. Spectrum
10.4103/mgmj.mgmj_117_23 of histopathological lesions of heart: An autopsy study at tertiary care center.
MGM J Med Sci 2023;10:389-96.

© 2023 MGM Journal of Medical Sciences | Published by Wolters Kluwer ‑ Medknow 389
 Pandey, et al.: Spectrum of histopathological lesions of heart
Many cardiac lesions are occult and found incidentally
on histopathological evaluation of samples of whole
heart specimens sent for postmortem examination. The
vast spectrum of lesions diagnosed on histopathology
after autopsy can help study these disease's epidemiology,
pathophysiology, and management modalities.[2]
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The study aimed to identify the various histopathological
lesions of the heart found incidentally and which may play
a significant role as a cause of death.
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Aims and objectives
1. To investigate the range of histopathological heart
lesions.
2. To analyze the demographic attributes of the study
cohort.
3. To examine alterations in the heart and blood vessels
through macroscopic examination.
4. To assess changes in the heart and blood vessels through
microscopic examination.
MATERIALS AND METHODS
Study design
This cross-sectional descriptive study was carried out at
the Department of Pathology in Pt. Jawahar Lal Nehru
Memorial Medical College, located in Raipur, Chhattisgarh,
India. The study was conducted over 1 year, starting in
January 2020 and concluding in December 2020.
Inclusion criteria
All the whole heart specimens received in 10% formalin
at the Department of Pathology for histopathological
evaluation were included in this study. A total of 209
specimens were received at the autopsy section of the
Department during the study period. Out of 209, one
sample was autolyzed. A total of 208 samples were included
in this study.
Exclusion criteria
Autolyzed or poorly preserved specimens of the heart
received in fragments were excluded from the study.
Gross examination
Specimens were examined externally for any visible
pericardial pathology. Areas of myocardial infarction,
rupture, and discoloration were noted, that is, whether
recent or old, and measured. Each specimen was weighed
after removing extraneous vessels and residual postmortem
blood clots.
390
Specimens were dissected by the inflow-outflow
method of cardiac dissection. Wherever required, the
short-axis procedure was followed. All the chambers
were washed off for blood clots and examined for any
valve pathology, including stenosis or calcification. The
endocardium was inspected for vegetation or thrombi.
The thickness of both ventricular walls and inter-
ventricular septum was measured. Areas of myocardial
ischemia were serially sectioned and noted for location
and size.
The two main vessels, the right coronary artery (RCA) and
left coronary artery (LCA), were examined using sections
at regular intervals of 4–5 mm for any hardening, blockage,
and plaque. The aorta was checked for any dilatation,
thickening, and atheromatous plaque.
Microscopic examination
Sections were taken from the right and left ventricular wall,
interventricular septum, apex, and multiple sections from
all the coronary arteries. In addition, sections were taken
from suspected pathological lesions. All sections were
stained with routine Hematoxylin and Eosin staining and
examined under a light microscope using 10× and 40×
objectives, and results were recorded.
Statistical analysis
The data obtained were statistically analyzed, and suitable
statistical formulas were applied.
OBSERVATIONS AND RESULTS
Two hundred-eight specimens were analyzed for gross
microscopic and demographic features.
Demographic features
The youngest case was of a newborn, and the oldest was
85, forming an age range of 0–85 years. The average age
of the study population is 42 years. A maximum number
of cases (30%) were presented between the ages of
31–45 [Table 1]. Of 208 patients, 164 (79%) were males,
and 44 (21%) were females. There was remarkable male
dominance [Figure 1].
Table 1: Age-wise distribution of study population
Range of age (in years) Number %
0–15 07 03
16–30 54 26
31–45 62 30
46–60 59 28
>60 26 13
Total 208 100
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 Pandey, et al.: Spectrum of histopathological lesions of heart

Table 4: Increase thickness of LVW and RVW (n = 208)

Sex wise distribuon of Study Populaon Feature Number of cases % of cases
(n=208) Increased thickness of LVW 57 27.4 (57/208)
Increased thickness of RVW 70 33.5(70/208)

n=44 (21%)
Gross Features of Le Coronaty Artery
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n= 164( 79%)
(n=208)
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Male Female
n=31(15%)
Thickened LCA
Figure 1: Sex-wise distribution of the study population
Calcified LCA

n= 65(31.25%) LCA occluded by thrombus

Table 2: Cardiomegaly in study population n-3(1.4%)

Gender Number of cases % of cases

Male (164) 37 23 (37/164)
Female (44) 11 25 (11/44)
Total (208) 48 23 (48/208)
Figure 2: Gross features of left coronary artery

Table 3: Fatty streak in study population Table 5: Gross findings of right coronary artery (n = 208)
Gender Number of cases % of cases Feature Number of cases % of cases
Male (164) 24 14.6%(24/164) Thickened RCA 27 13 (27/208)
Female (44) 09 0.2% (09/44) Calcified RCA 02 0.09(02/208)
Total (208) 33 15.8%(33/208) RCA occluded by thrombus 60 28.8(60/208)

Gross features
The weight of the heart ranged from 12 to 620 g. The
average weight of the heart was 282.6. The importance of
the heart went from 12 to 492 g in females and 26 to 492 g
in males. The average weight of the heart was 262.4 g in
females and 288 g in males. The weight of cardiomegaly,
defined as an increase in weight of the heart >300 g in females
and >350 g in males,[3] was found in 48 (23%) cases. Of 48
patients, 37 (77%) were found in males and 11 (23%) in
females [Table 2].

Fatty streak area was seen in 33 (15.8%) cases. Of 33

patients, 24 were found in males, and 09 were found in
females [Table 3]. Increased thickness of the free left
ventricular wall (defined as more than 1.5 cm)[3] was found
in 57 (27.4%) cases. Increased thickness of the free right
ventricular wall (defined as more than 0.5 cm)[3] was found
in 70 (33.5%) patients [Table 4]. Figure 3: Aorta showing fatty streak (earliest lesion) (H&E, 100x)

The LCA was found to be thickened on gross examination Microscopic features

in 31 (15%) cases. Calcification of LCA was seen in 03
(1.4%) cases. LCA was found to be occluded by thrombus
in 65 (31.2%) cases [Figure 2]. The RCA was found to
be thickened on gross examination in 27 (13%) cases.
Calcification of RCA was seen in 2 (0.09%) patients. In 60
(28.8%) cases, RCA was occluded by a thrombus [Table 5].
Out of 208 cases, 94 (45%) cases showed features of early
and advanced atherosclerosis [Figures 3–9]. Sixty-five
(32.6%) cases showed early and late features of myocardial
infarction [Figure 10]. Twenty-nine (14%) cases showed
features of myocardial hypertrophy [Figure 11]. Myocarditis
and pericarditis were seen in one patient each. RBCs with

MGM Journal of Medical Sciences | Volume 10 | Issue 3 | July-September 2023 391

 Pandey, et al.: Spectrum of histopathological lesions of heart
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Figure 4: Aorta showing atherosclerosis with calcification (H&E, 40x)
Figure 5: Coronary artery showing early atherosclerosis (H&E,40x)
sickle cell morphology were seen in three (1.4%) cases
[Figure 12]. One case showed metastasis of a poorly
differentiated tumor [Figure 13]. In 90 (43%) cases, there
was no identifiable cause of death, even after a complete
gross and microscopic autopsy [Table 6].
DISCUSSION
Histopathological examination of the heart helps attribute
the cause of death to cardiovascular disease. Autopsy helps
to study the morphological features of the heart, which
is impossible in the living, and to correlate it with the
clinical diagnosis.[2] The autopsy study provides a means of
understanding the primary process, which sets the stage for
clinically significant atherosclerotic cardiovascular disease.
There is no valid method of sampling the living population.
Therefore, death suspected due to cardiovascular pathology
392
Figure 6: Coronary artery showing atherosclerosis with calcification
(H&E, 40x)
Figure 7: Coronary artery showing atherosclerosis with narrowing of
the lumen (H&E, 40x)
probably provides the best sample of the living population
for studying cardiovascular diseases.[4]
A maximum number of cases were found within the
age range of 31–45 years, followed by the age range of
46–60 years. Similar findings were reported by Shilpa et al.
41–60 years, Karanfil et al., having a maximum case in the
41–50 years age range, Rao et al. in 50–60 years, and Chug
et al. in 50–59 years.[5-8] Age is a significant risk factor for
developing heart disease; age increases the probability of
developing heart disease. But the trend is now shifting
towards younger age. This may be because of unhealthy
lifestyle changes and various addictions like indulgence in
alcohol and smoking prevailing in the younger population.
MGM Journal of Medical Sciences | Volume 10 | Issue 3 | July-September 2023
 Pandey, et al.: Spectrum of histopathological lesions of heart
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Figure 8: Coronary artery showing thrombus with recanalization
(H&E, 40x)
Figure 9: Coronary artery showing thrombus with recanalization
(H&E, 40x)
Figure 10: Myocardial infarction (H&E, 40x)
MGM Journal of Medical Sciences | Volume 10 | Issue 3 | July-September 2023
Figure 11: Myocardial hypertrophy (H&E, 400x)
Figure 12: Coronary vessel showing sickle cells in lumen (H&E, 400x)
In this study, males were 79%, and females were 21%.
Males are at greater risk as compared to females as far
as the development of heart disease is concerned. The
vasoprotective effect of estrogen in females is an established
cause of a lower incidence of cardiovascular diseases in
females. Other studies also showed male predominance; a
study by Garg et al. showed 76% were males and 24% were
females,[8] and a study by Shah et al. showed 92.76% were
males and 7.24% were females.[9]
Cardiomegaly was seen in 48 (23%) cases. Of 48 patients,
37 (77%) were found in males and 11 (23%) in females.
Cardiomegaly is one of the gross manifestations of various
cardiac diseases, including hypertensive cardiomyopathy,
arrhythmias, and valvular and heart disorders.
393
 Pandey, et al.: Spectrum of histopathological lesions of heart

lesions increased with age from 8% at 2–15 years of age to

69% at 26–39 years of age.[11,12] However, the prevalence
of fatty streaks was less in our study.

Increased thickness of the free left ventricular wall was

found in 57 (27.4%) cases. Increased thickness of the free
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right ventricular wall was found in 70 (33.5%) patients.

Increased thickness of ventricular walls was probably
attributed to hypertrophy. In a study by Singhal et al.,[13]
86% showed left ventricular hypertrophy, 4% showed right
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ventricular hypertrophy, and 10% showed left and right

ventricular hypertrophy, compared to 37%, 2%, and 61%,
respectively, in a study by Bhaskar and Joshi et. al.[14]

The LCA was found to be thickened on gross examination in

31 (15%) cases. Calcification of LCA was seen in 03 (1.4%)
cases. LCA was found to be occluded by thrombus in 65
Figure 13: Metastatic tumor infiltrating myocardium (H&E, 40x)
(31.2%) cases. The RCA was found to be thickened on gross
examination in 27 (13%) cases. Calcification of RCA was
Table 6: Histopathological findings of heart on microscopic
examination (n = 208) seen in 2 (0.09%) patients. RCA was found to be occluded
by thrombus in 60 (28.8%) cases. Lesions of LCA were more
Features Number % of cases
of cases
than that of RCA in this study. In the study by Singhal et al.,
Atherosclerosis of the coronary 94 45 (94/208) the major blockage was noted in the LCA in 48 cases (60%),
artery left anterior descending artery (LADA) in 19 patients (25%),
Myocardial infarction 65 32.6 and RCA 12 cases (15%).[13] Rao reported 24 (11.8%) cases
(65/208)
Myocardial hypertrophy 29 14 (29/208) with significant blockage in both main coronaries, 87 (42.6%)
Myocarditis 01 0.04 (01/208) patients in LADA, and 18 (51.5%) cases in RCA.[15]
Pericarditis 01 0.04 (01/208)
Sickle cells in lumen of blood vessels 03 1.4 (03/208)
Metastatic deposits 01 0.04 (01/208) Of 208 cases, 94 (45%) showed early and advanced
No specific findings 90 43 (90/208) atherosclerosis features. Similar findings were reported by
Garg et al., 55.3%[8]; Ramazan Karanfil et al., 75%; Stavroula
In a study by Akosa et al., cardiomegaly was found in 12.2% et al., 77%; and Chandrakala Joshi, 64%.,[5,14,16] and Shah
of cases, almost half as seen in our research. The causes Saloni et al. 61.18%.[9]
of cardiomegaly were essential hypertension in 55% of
patients and hypertension of renal origin in 23.4% of cases. Sixty-five (32.6%) cases showed early and late features of
Cardiomyopathies, cor pulmonale, chronic rheumatic heart myocardial infarction. In the study by Garg et al., myocardial
diseases, ischemic heart diseases, chronic severe anemia infarction was present in 20(14.1%) cases. Similarly, Bora
(essentially Sickle cell origin), and congenital heart diseases Ozdemir et al. reported myocardial infarction in 26% of
accounted for 6.1%, 4.6%, 3.6%, 3.3%, 1.8% and 0.8% of cases.[17] Ramazan et al. reported myocardial infarction in
cases, respectively.[10] In our study, we have not evaluated 48% of cases, higher than our study. In contrast, Wang
the causes of cardiomegaly, which is one limitation of et al. said ischemic heart disease in 7% of cases, which is
our study. lower than this study.[6,18] This difference may be due to
time variability between the onset of ischemia and the time
Fatty Streak has been seen in 33 (15.8%) cases. Of 33 points, of death. Because microscopic features depend upon the
24 were found in males, and 09 were found in females. period between the beginning of ischemia and death.[7]
A fatty streak is the earliest lesion of atherosclerotic disease
of the heart, and it may be a flat or raised yellow plaque on Twenty-nine (14%) cases showed features of myocardial
the wall of the aorta. Not all lesions progress to advanced hypertrophy. In a Garg et al. study, myocardial hypertrophy was
lesions. In the Bogalusa Heart Study,[11] the prevalence of present in 10 (7.09%) cases.,[8] 7% was reported by Cristino
fatty streaks in the coronary arteries increased with age from Basso et al. and Wang et al.[18,19] Ramazan Karanfil et al. and
approximately 50% at 2–15 years of age to 85% at 21– Chandrakala et al. reported a much higher incidence of cardiac
39 years of age, and the majority of raised fibrous-plaque hypertrophy in 66% and 52% of cases, respectively.[5,14]

394 MGM Journal of Medical Sciences | Volume 10 | Issue 3 | July-September 2023

 Pandey, et al.: Spectrum of histopathological lesions of heart
Myocarditis and pericarditis were seen in one case each
in this study. A study by Garg et al. showed 5 (3.5%)
cases of myocarditis.[8] Different authors have reported a
variable percentage of myocarditis. Chandrakala Joshi 9%,
Cristina Basso et al, 10%, Bora Ozdemir et al., 7%, Drory
et al., 25% and Kramer et al., 29%.[14,17,19-21] In a Garg et al.
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study, pericarditis was found in 4 (2.8%) cases,[8] whereas
Chandrakala Joshi reported pericarditis in only 0.86% of
cases.[14]
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Red blood corpuscles (RBCs) with sickle cell morphology
were seen in three (1.4%) cases. Chhattisgarh is a belt of
sickle cell disorders. Sickle cell disease (SCD) is highly
prevalent in central, southern, and western India, with
frequency ranging from 10% to 23%.[22,23] Among all states,
this disease is more prevalent in Maharashtra, Madhya
Pradesh, Chhattisgarh, and Tamil Nadu.[24] The prevalence
of sickle cell anemia in Madhya Pradesh, including
Chhattisgarh, is 1%–40%.[25] Central India region is a
focus of sickle cell disorder.[26] So, the findings mentioned
above may be expected in coronary arteries with or without
thrombus. During the autopsy, it is essential to consider the
possibility of SCD in case of unexplained death. So, proper
histopathological examination, hemoglobin electrophoresis,
and molecular studies are needed to reach the causes of
death. It would also be helpful to their relatives to know
their family’s disease status, which could propel them to
seek timely relevant management to prevent SCD-related
morbidity and mortality.[14]
In the current investigation, there is a case showing the
metastasis of a poorly differentiated tumor. Dhankar et al.
previously conducted a study where they reported a case
of metastatic squamous cell carcinoma with the presence
of atypical squamous cell nests in the myocardium. This
case involved a patient diagnosed with squamous cell
carcinoma.[2] In addition, in a study conducted by Verma
et al., four carcinoma cases were identified.[27]
Out of the total cases, 90 (43%) did not reveal any discernible
cause of death despite conducting a comprehensive gross
and microscopic autopsy. In the studies conducted by
Verma et al. and Singal et al., 11% and 25% of cases,
respectively, also did not yield an identifiable cause of
death.[13,27]
CONCLUSION
A higher prevalence of cardiovascular diseases is observed
in males aged between 31 and 45. The predominant
histopathological observation is atherosclerosis, with
myocardial infarction being the second most common
MGM Journal of Medical Sciences | Volume 10 | Issue 3 | July-September 2023
finding. A thorough histopathological examination is
essential to ascertain the cause of death, particularly in
cases where individuals are asymptomatic.
Limitations
Our research did not investigate the causes of death or
the origins of histopathological lesions. Furthermore, we
could not employ supplementary techniques to enhance
histopathological examination due to resource constraints.
These techniques include three Tesla magnetic resonance
imaging (3T-MRI), histochemical staining using triphenyl
tetrazolium chloride, and quantitative myoglobin assay.
Ethical policy and institutional review board statement
Approval to carry out the research protocol titled
“Examining the Range of Histopathological Heart Lesions:
An Autopsy Investigation at a Tertiary Care Center” has been
obtained from the Institutional Ethics Committee (IEC) at
Pt. Jawahar Lal Nehru Memorial Medical College, Raipur,
Chhattisgarh, India. This confirmation is officially recorded
in a letter reference no. MC/Ethics/2023/57, issued on
September 8, 2023.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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MGM Journal of Medical Sciences | Volume 10 | Issue 3 | July-September 2023