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The Pathology of Cardiac Interventions

The Pathology of Cardiac Interventions. Dr Stephen Preston Royal Bournemouth Hospital Dr Patrick J Gallagher University of Southampton. Problems for the Pathologist. As the number of interventions increase all pathologists will perform autopsies on patients with stents

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The Pathology of Cardiac Interventions

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  1. The Pathology of Cardiac Interventions Dr Stephen Preston Royal Bournemouth Hospital Dr Patrick J Gallagher University of Southampton

  2. Problems for the Pathologist • As the number of interventions increase all pathologists will perform autopsies on patients with stents • Finding and dissecting stents can be difficult • Two questions: is the stent patent? If not is it thrombus or fibrous tissue? • What is the appearance of the myocardial infarct?

  3. No endothelium

  4. Late DES failure 14 (61%) had stent thrombosis (one died of stroke) 4 cardiac deaths 23 DES cases, died >30 days post procedure 7 (30%) had patent stent(s) 3 non-cardiac deaths 2 (9%) had stent restenosis (both died of AMI/SCD) Joner M et al, J Am Coll Cardiol 2006;48:193-202

  5. Pathological factors in stent thrombosis • Delayed endothelial coverage • Necessary for thrombosis, rare in bare metal stents • Maximum mean DES coverage 60-70% • More common with ruptured plaques • Pro-thrombotic material • Thrombus • Penetration of necrotic plaque core • Hypersensitivity/inflammation? • Abnormal flow • Malapposition • Restenosis

  6. Limitations to the coroner’s autopsy • Coroner’s duty: • Who died, when, where and how • Purpose of autopsy in non-suspicious cases: • Provide a medical cause of death • Finance • 112 coroners, £71million total budget • 50% on autopsy, mortuary, toxicology etc • Human tissue act • Training of pathologists

  7. Solutions • Improved training for registrars in histopathology • UK Cardiac Pathology Network • Chief coroner? • Medical examiners?

  8. References • Carlsson J et al. Is late stent thrombosis a real clinical issue? A single-center experience and review of the literature. Clin Res Cardiol 2007;96:86-93. • Finn AV et al. Vascular responses to drug eluting stents: importance of delayed healing. Arterioscler Thromb Vasc Biol 2007;27:1500-10. • Finn AV et al. Does underlying plaque morphology play a role in vessel healing after drug-eluting stent implantation? J Am Coll Cardiol Img 2008;1:485-8. • Joner M et al. Pathology of drug eluting stents in humans. Delayed healing and late thrombotic risk. J Am Coll Cardiol 2006;48:193-202. • Luescher TF et al. Drug-eluting stent and coronary thrombosis: biological mechanisms and clinical implications. Circulation 2007;115:1051-8.

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