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Concentric hemorrhagic necrosis of the myocardium. A morphological and clinical study
Insights
Concentric hemorrhagic necrosis of the left ventricle, a cardiac surgery complication, was studied in autopsy cases. This lesion, linked to cardiopulmonary bypass, showed evolving histological changes and varied with surgical techniques over time.
Area of Science:
- Cardiovascular Pathology
- Surgical Complications
- Myocardial Injury
Background:
- Concentric hemorrhagic necrosis (CHN) is a lesion observed in the left ventricular myocardium.
- This condition has been noted in patients undergoing cardiac surgery involving cardiopulmonary bypass.
Purpose of the Study:
- To analyze the gross and microscopic findings of CHN.
- To define the morphologic evolution and characteristics of CHN.
- To investigate changes in CHN incidence and severity over time and with different surgical techniques.
Main Methods:
- Review of 49 cases of CHN from 97 autopsy studies.
- Gross examination of serial transverse heart sections to grade lesion extent.
- Microscopic analysis to identify five sequential histologic changes.
- Subdivision of cases into two groups based on surgical periods (1963-1970 and 1971-1974).
Main Results:
- Identified five sequential histologic changes: contraction bands, subendocardial hemorrhages, coagulative necrosis, granulation tissue, and fibrosis.
- CHN location coincided with vulnerable microcirculation regions.
- CHN was less frequent but more pronounced in the recent surgical group (1971-1974).
- The earlier group (1963-1970) showed milder lesions with a higher incidence of platelet microthrombi.
- In recent cases, CHN was more diffuse in aortocoronary bypass than in valvular replacement surgery.
Conclusions:
- CHN likely results from transient hypoxemia during cardiopulmonary bypass, followed by reperfusion and accelerated necrosis with hemorrhage.
- Surgical advancements may have influenced the frequency and severity of CHN.
- Understanding the evolution of CHN is crucial for improving cardiac surgical outcomes.
Abstract:
Froty-nine cases of concentric hemorrhagic necrosis of the left ventricular myocardium were reviewed in a series of 97 autopsy studies in patients subjected to cardiopulmonary bypass for various types of cardiac surgery. The gross and microscopic findings were analyzed in order to define the morphologic evolution of the lesion. The extent of involvement was graded by gross examination of serial transverse sections of the heart. Microscopically there were five major histologic changes, probably representing the sequential evolution of the lesion, i.e., contraction bands, subendocardial hemorrhages, coagulative necrosis, healing by granulation tissue, and fibrosis. The location of the lesion conincided with the vulnerable region of the microcirculation. Owing to the implementation of new surgical techniques, the cases were subdivided into two groups, one covering the period from 1963 to 1970 and the other , 1971 to 1974. Concentric hemorrhagic necrosis was less frequent in the more recent group, but when it was present it was more pronounced in the individual heart. The lesion in the earlier group was milder but demonstrated a higher incidence of platelet microthrombi in the heart. In the recent cases concentric hemorrhagic necrosis tended to be more diffuse in aortocoronary bypass than in valvular replacement surgery. We discuss one possible explanation for the development of this lesion, i.e., transient hypoxemia occurring at the time of cardiopulmonary bypass, followed by reperfusion and accelerated necrosis with hemorrhage.
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