Proceedings of the Fourth Scientific Meeting of the World Society for Pediatric and Congenital Heart Surgery

World Journal for Pediatric and

Congenital Heart Surgery
Understanding the Morphology of the 2015, Vol. 6(2) 239-249
ª The Author(s) 2015
Reprints and permission:
Specialized Conduction Tissues in sagepub.com/journalsPermissions.nav
DOI: 10.1177/2150135115572376
Congenitally Malformed Hearts pch.sagepub.com

Vera Demarchi Aiello, MD, PhD1

Abstract
To repair congenital heart defects by means of open heart surgery, the surgeon needs guidance about the location and distribution
of the specialized conduction tissues, in order to avoid their direct damage and consequent conduction disturbances. This review
addresses the historical steps of the morphological study of the conduction system in different types of heart defects, providing
updated information about the subject.

Keywords
cardiac anatomy/pathologic anatomy, congenital heart surgery, surgery, complications, arrhythmia

Submitted December 9, 2014; Accepted January 15, 2015.

The Fourth Stella Van Praagh Memorial Lecture delivered at the 4th Scientific Meeting of the World Society for Pediatric and Congenital Heart Surgery,
Sao Paulo, Brazil; July 17-20, 2014.

Introduction transposition of the great arteries, but the development of cardi-

Stella Van Praagh and the Cardiac Morphologists: More than
Students and Educators, Partners of the Cardiac Surgeons!
More than a great honor and a privilege, delivering the Fourth
Stella Van Praagh Memorial Lecture at the 4th Scientific Meet-
ing of the World Society for Pediatric and Congenital Heart
Surgery was a big responsibility. Even more, when one consid-
ers the fact that the three previous lecturers have been none
other than her husband Richard Van Praagh, Professor Robert
H. Anderson, and James Wilkinson, three of the greatest icons
of cardiac morphology of our time.
Stella Van Praagh was one of the witnesses of the big devel-
opment of palliative and corrective surgery for congenital heart
defects in the early 1960s and 70s. At that time, there was an
increasing demand for accurate description of the normal and
abnormal heart structures, although as early as in the 19th cen-
tury several congenital heart defects already had their morpholo-
gical aspects well characterized. However, the true relevance of
a cardiac morphologist’s observation lies in the fact that it facil-
itates the surgical repair of simple or complex congenital defects.
And at that time, there were brand new demands to attend to,
especially those related to the safety of surgical manipulation
or resection inside the heart chambers. The very first intracavi-
tary procedures were not performed with direct inspection, like
the operation proposed by Alfred Blalock and Rollis Hanlon for
the creation of an interatrial communication1 in patients with
opulmonary bypass allowed closure of defects, valvuloplasties,
and myocardial resections under direct observation. Avoidance
of the specialized conduction tissue was a real concern at that
time. The first reports of surgical damage to the specialized con-
duction tissues were published as cooperative studies of sur-
geons and morphologists, like the report authored by the great
cardiovascular pathologist Jack Titus from Minnesota, together
with Daugherty, Kirklin,2 and Jesse Edwards (Figure 1).
It was our decision to review in this lecture some of the histor-
ical aspects of the process, which led to the full understanding of
the morphology of conduction tissues in congenital heart disease.
The Specialized Conduction Tissues in
Congenitally Malformed Hearts
Defects With a Normally Positioned
Atrioventricular Node
Studies about the histological anatomy of the conduction sys-
tem in malformed hearts were fundamental for the successful
1
Laboratory of Pathology, Heart Institute (InCor), Hospital das Clı́nicas da
Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
Corresponding Author:
Vera Demarchi Aiello, Instituto do Coração (InCor), HCFMUSP, Av. Dr. Enéas
C. Aguiar, 44, São Paulo, CEP 05403-000, Brazil.
Email: vera.aiello@incor.usp.br

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240 World Journal for Pediatric and Congenital Heart Surgery 6(2)

Figure 1. Histological sections of the atrioventricular conductions tissues as published in Titus et al2 showing damage (yellow arrows) to the
area of bundle branching by sutures during closure of a ventricular septal defect. Adapted and used with permission from Titus et al.2 RB indi-
cates right bundle; LB, left bundle.

correction of defects. Although there are reports of the descrip-

tion of bundle branches on the border of a ventricular septal
defect (VSD) attributed to Keith in the beginning of the 20th
century, still in the late 1940s many doubts remained about the
true existence of the cardiac conduction system,3 and the com-
plete elucidation of the course and location of bundles and
nodes had a big impulse with the development of techniques for
intracardiac repair. One of the pioneers in this field was Lev4-7
who clarified the histological aspects of the conduction axis in
several acquired heart diseases and also in congenitally mal-
formed hearts. The great morphologists Jack Titus and Jesse
Edwards also left their contribution in this field, having had the
opportunity to work together with the very first leaders of car-
diac surgery. Later, in the European School, Anderson, Becker,
and Ho were of paramount importance in the 1980s and 90s,
also working in association with cardiac surgeons.

Atrioventricular Conduction Tissues in Defects With

Aligned Septal Components
Nowadays, a young resident in cardiac surgery knows very well
about the distribution of the nonbranching bundle on the poster-
oinferior border of a perimembranous VSD, on the left ventri-
cular aspect8 (Figures 2 and 3). In all perimembranous defects,
the distribution is similar, whatever be the main extension of
the defect relative to the septal components (Figure 4). Even
the design of the modern devices used for percutaneous closure
of VSDs takes this anatomical feature into consideration in
order to avoid or minimize the risk of conduction blockage.
Should the defect be muscular, however, the situation is dis-
tinct, a fact well recognized by those closing such septal holes.
The muscular border protects the conduction bundle. In inlet
muscular defects extending anterosuperiorly, the conduction
axis is near the superior border, and for those located in the
Figure 2. Schematic representation of the atrioventricular conduc-
tion tissues in the presence of a perimembranous ventricular septal
defect. The bundle usually lies on the left ventricular aspect of the pos-
teroinferior border of the defect. The star marks the position of the
atrioventricular node. Modified, adapted, and used with permission
from Davies et al.9
trabecular portion of the septum, the bundle is far away from
the defect borders (Figure 5).
The VSD in tetralogy of Fallot, one of the first defects cor-
rected in the early days of cardiac surgery, shows its own pecu-
liarities. The outlet septum is deviated anterosuperiorly and,
together with the hypertrophied septoparietal trabeculations,
promotes subpulmonary stenosis (Figure 6). Lev was the first
one to describe the anatomy of the conduction tissues in Fallot.7
In more than 80% of the Fallot cases, the defect is

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Aiello
Figure 3. Right ventricular view of the atrioventricular transition,
showing a perimembranous ventricular septal defect (VSD) extending
slightly to the outlet. The yellow line shows the location of the atrio-
ventricular conduction axis.
perimembranous, and the branching bundle usually runs to the
left ventricular aspect of the defect, off the border. Infrequently
(in just over one of the ten cases), the branching bundle or both
bundle branch origins is located on the top of the ventricular
septum (straddling the septum), a feature well demonstrated
by Deanfield et al10 (Figure 7). Although potentially vulnerable
in these situations, the conduction axis is far from the sutures,
and the most vulnerable site for surgical damage is, as in other
perimembranous defects, the area of aortic, tricuspid, and
mitral fibrous continuity.
Elucidating the location and course of the specialized con-
duction tissue in atrioventricular (AV) septal defects was a
team job for pathologists, cardiologists, and surgeons. The clas-
sical description of Lev6 was corroborated by others.11,12 In all
variants of this type of defect, the defining feature is the pres-
ence of a common AV junction (Figure 8). Depending on the
adherence and fusion of the bridging leaflets to the septums and
between themselves, the shunt may be at the atrial ventricular
or on both levels. As a consequence of the absent normal AV
septation, the triangle of Koch and the AV node are always dis-
placed posteroinferiorly, close to the place where the ventricu-
lar septum raises to reach the common AV junction, also
closely related to the mouth of the coronary sinus (Figure 8).
Understanding this anatomical disposition was crucial for the
development of special surgical strategies in order to avoid
damage to the node itself. The nonbranching bundle is much
longer than usual, either lying on the left ventricular aspect
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241
Figure 4. Atrioventricular transition in a normal heart viewed from
the right-sided chambers. The membranous septum was transillumi-
nated (white arrows) and has an atrioventricular and an interventricu-
lar component. The dotted red lines correspond to the annulus of the
tricuspid valve, and the ovals depict the possible extensions of central
ventricular septal defects to the inlet, trabecular, and outlet parts of
the ventricular septum.
of the ventricular crest or embedded beneath the midline raphe
of the inferior bridging leaflet when it is attached to the septal
crest, as is demonstrated by the dashed line in Figure 9. The left
branch originates much more posteriorly than in the normal
heart and its radiations are extensive. When there is a single
valvar orifice, in the so-called complete or total form, the con-
duction axis, especially the right bundle branch, is partially
exposed to the bare area of the septum beneath the zone of
apposition between the superior and inferior leaflets. On the
other hand, if there is a connecting tongue joining the bridging
leaflets, the axis is hidden by this leaflet tissue (Figure 9).
Atrioventricular Conduction Tissues in Defects With
Malaligned Septal Components
It is not surprising nowadays even for the young cardiac sur-
geon that for hearts with discordant AV connections (called
anatomically corrected transposition when there is concomi-
tantly discordant ventriculoarterial connections), the non-
branching bundle courses on morphologically left ventricular
aspect of the anterosuperior border of a perimembranous VSD.
This morphological feature, a forgotten piece of information
described in the beginning of the 20th century by Aschoff, was
brought to light again by Lev in the 1960s,13 in the context of
corrective surgery. But the exact location of the AV node in this
malformation was not clarified until the works by Anderson,
Becker, and Wilkinson in the late 70s.14,15 Initially it was
242 World Journal for Pediatric and Congenital Heart Surgery 6(2)

Figure 5. These two hearts opened through the right ventricle show muscular ventricular septal defects (VSD) positioned in different parts of
the septum (trabecular and inlet). The yellow lines indicate the location of the conduction axis, running posteroinferiorly or anterocephalad
relative to the VSD.

Figure 6. This heart with tetralogy of Fallot shows the typical devia-
tion of the outlet septum and the overriding aorta. The yellow line
depicts the position of the atrioventricular conduction tissues on the
posteroinferior border of the ventricular septal defect.

believed that there was ‘‘complete inversion of the conducting

tissues’’ and even a left-sided AV node was described, as Lev
describes, laying ‘‘above and to the left of the central fibrous
body.’’ In some studies, this node could not be found and
researchers attributed this feature to the presence of a complete
heart block frequent in this malformation. Completely by
chance as he told me personally, Anderson found, when analyz-
ing sections of the branching bundle, the right-sided and ante-
riorly positioned AV node.
In the usual form of corrected transposition of the great
arteries, there is malalignment between the atrial and ventricu-
lar septums. The gap produced by such malalignment is either
filled by a large membranous septum or the place of a peri-
membranous defect, frequently overrided by the pulmonary
Figure 7. Histological section of the ventricular septum as published
by Deanfield et al, demonstrating the branching atrioventricular bun-
dle located on the crest of the ventricular septum (small arrows) in
a case of corrected tetralogy of Fallot. There was no surgical damage
to the conduction axis as shown by the site of sutures. Used with per-
mission from Deanfield et al.10
trunk that is deeply wedged between the AV valves. The regu-
lar AV node, usually hypoplastic and situated at the apex of the
triangle of Koch (Figure 10), is unable to make contact with the

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Aiello 243

Figure 8. These two hearts with atrioventricular septal defect were dissected differently. The upper panel shows a view of the common atrio-
ventricular junction and the aorta (Ao) displaced anterosuperiorly. The lower panel demonstrates a heart opened through the right ventricular
chambers. The atrioventricular node is displaced posteroinferiorly due to the deficiency of the atrioventricular septation. The initial part of the
nonbranching bundle is usually covered by the inferior bridging leaflet but the anterior part lies on the bare surface of the crest of the ventricular
septum.

Figure 9. The left-sided panel shows a heart with atrioventricular septal defect with two valvar orifices due to the fusion of the bridging leaflets.
Such tissue fusion protects the long atrioventricular conduction axis from surgical damage during defect correction. The right panel shows in a
histological section the presence of a bundle branch hidden by the leaflet tissues.

ventricular myocardium due to the extensive gap described ear- The course of the nonbranching bundle is very long, encircling
lier. So, the node that connects with the ventricular bundle is the left ventricular outflow tract anterosuperiorly before des-
positioned anteriorly in the mitral valve annulus (Figure 10). cending and distributing on the septal surface (Figure 11).

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244
Figure 10. Schematic representation of the base of the heart in a
heart with discordant atrioventricular connections, demonstrating the
location of the anomalous atrioventricular node and atrioventricular
conduction tissues. Adapted and used with permission from Anderson
et al.15
Figure 11. This heart with anatomically corrected transposition of
the great arteries was opened through the morphologically left ventri-
cle (LV). The yellow lines show the location of the ventricular conduc-
tion tissues, penetrating at the anterior mitral annulus, coursing
around the root of the pulmonary trunk, and running on the antero-
superior border of the ventricular septal defect (VSD). The dotted line
represents the area of pulmonary trunk opening.
Sometimes, an additional posterior connecting node is found
and a complete sling of conduction tissue runs on the VSD bor-
der (Figure 12). This later finding was further analyzed by other
investigators who clarified additional aspects of the conduction
tissues in the presence of associated lesions that provide better
alignment of the septums, like overriding of the mitral valve or
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World Journal for Pediatric and Congenital Heart Surgery 6(2)
Figure 12. This heart with discordant atrioventricular connections
and straddling mitral valve was opened through the right-sided cham-
bers (morphologically right atrium and left ventricle). The lines depict
the presence of a sling of conduction tissue on the border of the ven-
tricular septal defect. Adapted and used with permission from Kuro-
sawa et al.16
else pulmonary atresia. In this regard, the partnership between
surgeons and morphologists is also acknowledged. Kurosawa
and Becker described in 199016 a case with mitral valve strad-
dling and overriding, which presented a posterior node origi-
nating a regular and also posterior connecting bundle (Figure
12). In this publication, they emphasized the importance of
alignment of the septa in the disposition of the AV conduction
tissues.
A few years ago, Hosseinpour and colleagues17 provided
new evidence to explain the finding of a posterior node and
connecting bundle in some cases of corrected transposition.
They studied such hearts and concluded that when there is pul-
monary atresia or severe pulmonary stenosis, the gap produced
between the septa at the crux of the heart is much smaller as
seen in Figure 13. In this situation, it is likely that both systems
(anterolateral and posteroinferior) occur concomitantly instead
of isolated anterolateral node and bundle. This produces the
so-called ‘‘Mönckeberg sling’’ of conducting tissue described
far back in the second decade of the 20th century. It is also pos-
sible that this smaller gap can explain the finding of a regular
posteroinferior node in cases of corrected transposition and
mirror-image atrial arrangement or situs inversus, since in all
situs inversus specimens studied so far there was pulmonary
stenosis or atresia.18
Hearts With Univentricular AV Connections
The rule of septal alignment should also be considered in hearts
with univentricular AV connections, with differences in the
position of conduction tissues according to the morphology
of the main ventricle (Table 1).19-21 When the main chamber
is of left morphology, the trabecular septum does not reach the
crux cordis, which is not the case when the dominant ventricle
Aiello 245

Figure 13. This cartoon shows how the presence of a hypoplastic or atretic pulmonary trunk can lead, in hearts with discordant atrioventri-
cular connections, to better atrioventricular septal alignment and thus to the presence of two connecting atrioventricular noses. Adapted and
used with permission from Hosseinpour et al.17

Table 1. Rule of ‘‘Septal Alignment’’ and the Conduction Tissues in

Hearts With Univentricular Atrioventricular Connections.

 Ventricular septum does not reach crux if main ventricle is of LEFT

morphology
Anomalous anterosuperior or lateral atrioventricular node
Relation of bundle to VSD borders depends on the position of
the rudimentary chamber
 Ventricular septum at crux if main ventricle is of RIGHT
morphology
Regular atrioventricular node
 Variable position of AV node and bundle in solitary ventricles
INDETERMINATE morphology
Abbreviations: AV, atrioventricular; VSD, ventricular septal defect.

is of right morphology. Because of septal malalignment, in

cases with dominant left ventricles, the connecting AV node
is situated either at the anterolateral ring of the right AV valve
in double inlet ventricles or on the floor of the bind-ended right
atrium in classical tricuspid atresia22 (Figure 14). The distribu-
tion of the bundle branches relative to the VSD depends on the
position of the rudimentary chamber of right ventricular mor-
phology. The possibility of enlargement of a VSD in these
hearts with a rudimentary right ventricle is also a concern that
needs to be addressed, both in primarily restrictive defects and
in the status postpulmonary trunk banding as a stage for total
cavopulmonary connection.23 The VSD border at risk for
resection depends upon the position of the rudimentary right
ventricle. If it lies to the right, the bundle is located on the pos-
teroinferior border, but if on the left, the anterosuperior border
is the one that carries the specialized conduction tissue. As a
general rule, the bundle branch lies on the left ventricular
Figure 14. Opened right atrium in a case of absent right atrioventricu-
lar connection. The star shows the anticipated site of the atrioventricu-
lar node on the floor of the atrium. ICV indicates inferior caval vein.
aspect of the trabecular septum, on the VSD margin that is clo-
sest to the anticipated site of the AV node (Figure 15). In the
presence of a left-sided rudimentary ventricle, the right border
of the VSD is an anterior structure and is separated from the
AV node by the outflow tract and the great artery connected
to the main ventricle. So the nonbranching bundle is a long
structure, similar to what is observed in the setting of corrected
transposition of the great arteries.

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246
Figure 15. Anterior aspects of three hearts with univentricular atrioventricular connections showing the different positions of the morpho-
logically and rudimentary right ventricle. The crescent shapes indicate the border of the ventricular septal defect carrying the atrioventricular
conduction tissues.
On the other hand, in hearts with a dominant right ventricle,
the trabecular septum reaches the crux, irrespective of the right-
sided or left-sided rudimentary left ventricle. Hence, a regular
posterior AV node is found at the apex of the triangle of Koch,
and the penetrating bundle is able to make contact with the inlet
ventricular septum.24
A few hearts with univentricular AV connections to a soli-
tary ventricle of indeterminate morphology have been studied
in regard to the AV conduction tissues. Because there is no ven-
tricular septum, no rule can be drawn concerning the conduc-
tion axis. Wilkinson and colleagues25 found anterior or
anterolateral nodes in the hearts studied and the AV bundle
penetrating directly at the right lateral wall of the indeterminate
ventricle or through a large muscular trabecula. Table 1 sum-
marizes the findings of the conduction tissues in univentricular
hearts.
Overriding AV Valves
Hearts with overriding AV valves also show malaligned sep-
tums. There are striking differences, though, between tricuspid
and mitral valve overriding (Table 2). The tricuspid valve over-
rides the inlet septum, which consequently does not reach the
crux cordis. The regular node at the apex of the triangle of
Koch does not give rise to the penetrating AV bundle. Instead,
an anomalous posteroinferior or posterolateral node at the site
where the trabecular septum reaches the atrial wall is the one
that originates the nonbranching bundle. The conduction axis
runs on the bare surface of the inlet ventricular septum and is
a concern during defect correction. Also, avoidance of the node
itself is crucial (Figure 16).9
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World Journal for Pediatric and Congenital Heart Surgery 6(2)
On the other hand, the mitral valve overrides the outlet sep-
tum (Figure 17), and at the crux, there is full septal alignment,
with regularly positioned node and bundle branches. Of course,
the degree of overriding will define the AV connection as
biventricular or univentricular. So, the key feature for delineat-
ing the node and bundle position is, in this group of malforma-
tions, the alignment of the septums at the crux cordis (Table 2).
Ebstein’s Anomaly
The possibility of valve repair in Ebstein’s anomaly brought
new concerns about the conduction disturbances that are fre-
quent in the malformation. Whatever be the surgical technique
used, it is important to understand the morphological substrate
of preexcitation. For some time it was believed that the AV
junction in Ebstein’s anomaly showed an inherent weakness,
thus providing holes that would account for muscular bridges
or connections. Lev in 195526 demonstrated that this was not
the case. A further study carried out by Ho and coworkers in
five heart specimens showed fibrofatty separation between the
atria and the ventricles in all cases, despite the thin myocardial
walls.27 Lateral muscular connections were present in two
cases, and accessory nodoventricular connections in four speci-
mens. The compact AV node was closer to the coronary sinus
than in normal hearts, and there was also hypoplasia or absence
of the right bundle branch in four cases (Figure 18). All these
morphological features should be considered by the cardiac
surgeon together with the electrophysiologist. A full preopera-
tive study of the conduction disturbances should be carried out
in order to avoid the need of postsurgical procedures over an
area of sutures and fibrous healing, which could bury the
Aiello
Table 2. Conduction Tissues in Overriding Atrioventricular Valves.
 Tricuspid valve overrides the inlet septum
Septum does not reach crux
Anomalous node at the point where the ventricular septum
reaches the inferior atrial wall
 Mitral valve overrides the outlet septum
Trabecular septum reaches crux
Regular posteroinferior AV node
Abbreviation: AV, atrioventricular.
Figure 16. Opened right atrium showing the tricuspid valvar orifice
overriding the inlet ventricular septum. The anomalous node is
located at the site where the ventricular septum reaches the inferior
right atrial wall. The atrioventricular bundle runs on the bare surface
of the ventricular crest.
anomalous connections, making them inaccessible for future
catheter ablations.
The Sinus Node and AV Conduction Tissues in Hearts
With Isomerism of the Atrial Appendages
Morphological studies were also fundamental to clarify the
location of sinus and AV nodes in hearts with isomeric atrial
appendages. This group of cardiac malformations presents a
large morphological spectrum, including severe abnormalities
of the pulmonary and systemic venous returns, with complex
and challenging problems for surgical palliation and repair.
Smith and colleagues published a detailed study about the
location of the nodes and the course of the AV bundle in 35
hearts with isomeric atrial appendages.28 Summarizing the
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247
Figure 17. Heart specimen opened through the left cardiac chambers
showing the mitral valve overriding the anterior part of the ventricular
septum. LV indicates left ventricle.
findings, most hearts with right isomerism show double sinus
nodes, accompanying the direct connection of the superior
caval veins to each of the atria on the epicardial surface of the
terminal grooves (Figure 19). Any corrective or palliative sur-
gical procedure performed on the atrial walls or involving their
coronary supply should be planned, taking into account the
information about sinus node location, in order to avoid the
structures harboring the specialized tissues.
On the other hand, hearts with left isomerism show either a
nondetectable sinus node in over 50% of cases or a hypoplastic
node abnormaly located near the AV junction. When present in
left isomerism, the hypoplastic sinus node is usually found
within the myocardium of the right-sided atrium. Thus, a defi-
nitive rule for the location of the sinus node in the setting of left
isomerism cannot be formulated.
On its turn, the spatial disposition of the AV node and bun-
dle in this group of anomalies will depend on the ventricular
topology and type of AV connection, following also the septal
alignment rule. Whenever there is left-hand ventricular topol-
ogy, the AV conduction tissues were found to be anomalous.
All right-isomerism specimens showed two AV nodes, while
single AV nodes were found in the majority of left isomerism
cases. Moreover, disconnection between the AV node and the
ventricular conduction axis was a common finding in left iso-
merism (Figure 20).
Perspectives and Future Directions for
Correlation Studies in Cardiac Morphology
As extremely dedicated students and educators, a whole era of
cardiac morphologists established an outstanding model for
248
Figure 18. Right-sided cardiac chambers opened in a case with
Ebstein’s anomaly of the tricuspid valve. The septal and inferior leaflets
are plastered against the ventricular inlet. The dotted line marks the
site of the right atrioventricular junction or the true tricuspid valve
annulus.
Figure 19. The sinus node in different types of arrangement of the
atrial appendages. Adapted and used with permission from Davies
et al.9
tutoring pediatric cardiologists and surgeons in training. A lot
has been studied and learned about the heart anatomy, includ-
ing the specialized conduction tissues in congenital heart dis-
ease. Most of the contributions were derived from the
conjoined efforts of pathologists, surgeons, and cardiologists
to fulfill the requirements of open heart surgery. Although the
elucidation of the course of conduction tissues demanded
detailed histological studies, this is not the case for other
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World Journal for Pediatric and Congenital Heart Surgery 6(2)
Figure 20. Schematic representation of the commonest patterns of
atrioventricular conduction tissues in cases of isomerism of the atrial
appendages. In the cases studied by Smith et al,28 all cases with right
isomerism presented with two connecting nodes. On the other hand,
most cases of left isomerism had a single atrioventricular node and
nodoventricular disconnection. Adapted and used with permission
from Smith et al.28
morphological features in such hearts. Today, the presence and
quantification of fibrosis, necrosis, and coronary obstruction
can be easily obtained by magnetic resonance imaging and
computerized tomography.
New demands for correlation studies will certainly continue
to appear for diverse aspects of pre- and postsurgical gross
anatomy. A new team of morphologists is taking the scene and
may gradually replace the classical pathologists. They are the
image professionals, taking advantage of the tools that allow
high-resolution analysis of the heart and vessel’s morphology,
even three-dimensional reconstructions, always working
together with surgeons, cardiologists, and interventionists.
Preparing this lecture was very inspiring. Having come
across the seminal publications and the multiple pictures of
morphologists in their daily practice, always surrounded by
curious young doctors make us feel confident that the long-
standing partnership between surgeons and morphologists (the
classical ones and the modern ones—the image professionals)
will go on for the well-being of patients with congenital heart
defects.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship,
and/or publication of this article.
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