CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

NOTE: Please review all complex or “interesting” gross specimens with Dr.
Michael Fishbein or Dr. Gregory Fishbein.
Specimen Type: ENDOMYOCARDIAL BIOPSIES
Procedure:
1. Measure and describe, noting number of pieces (if > 5, state, “greater than 5”),
color.

Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and
received [fresh/in formalin] are [#] fragments of [color] soft tissue fragments measuring
[sizes]. Entirely submitted in [cassette summary].

Cassette Submission:
For tissue received in formalin, submit entire specimen between blue sponges or in a
tea bag and processed with H&E x 3 protocol.
Saline soaked fresh tissue, if present, should be sent to the IHC lab for
immunofluorescence. Transplant cases will receive the standard transplant protocol.
Discuss native biopsy cases with the attending to determine what IF stains should be
performed.
Tissue in glutaraldehyde, if present, should be sent to the EM lab.

Specimen Type: NATIVE HEART VALVES

Procedure:
1. Take gross photographs
2. Measure, range and aggregate
3. Document presence of lesions, vegetations, calcifications
4. Comment on attached chordae tendinae, if present
5. Log as gross only as specimens may be reviewed at a later time or kept for
teaching purposes

Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and
received [fresh/in formalin] is a [mitral/aortic] valve measuring *** x *** x *** cm. The
[cusps or leaflets] are [yellow, smooth, calcified, and intact]. Tears in the leaflets
[are/are not] identified. The chordae tendineae are [intact/ruptured/fused/thickened].
The papillary muscles are [hypertrophied/unremarkable/]. Vegetations [are/are not]
identified. Gross photographs are taken. Representative sections are submitted,
following decalcification [describe cassette submission].
Cassette Submission: One cassette of representative tissue, decal as needed

Page | 1
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

Specimen Type: PROSTHETIC CARDIAC VALVES

Procedure:
1. Take gross photographs and x-rays
2. Measure
3. Document presence of lesions, vegetations, calcifications
4. Comment on degree of pannus formation (i.e. tissue overgrowth)
5. For bioprosthetic valves, submit sections of the leaflets
6. Log as gross only as specimens may be reviewed at a later time or kept for
teaching purposes

Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and
received [fresh/in formalin] is a [bioprosthetic/mechanical] valve measuring *** x *** x ***
cm. [Describe type of mechanical valve, the inflow and outflow tract, fused, presence of
calcifications or clot]. The leaflets are [yellow, smooth, calcified, intact]. Tears in the
leaflets [are/are not] identified. Vegetations [are/are not] identified. [Describe thickness

Page | 2
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

of cusps]. [Describe chordae tendineae, if present, noting thickening, shortening, or

fusion]. [Describe any papillary muscle that is included with the specimen]. A gross
photograph is taken. Representative sections are submitted [describe cassette
submission].
Cassette Submission: 1-2 cassettes of representative tissue (if present)
 Submit sections taken perpendicular to the surface of the valve
from the point of attachment to the free margin. Submit cross
sections of the chordae tendineae and the base of the papillary
muscles, if present.
 Decalcify the sections if necessary.
 NOTE: Review all artificial valves with an attending pathologist.

Specimen Type: ATRIAL APPENDAGES and OTHER NON-VALVULAR PORTIONS

OF HEART
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and
received [fresh/in formalin] is a red-brown portion of endocardial-lined myocardium
measuring*** x *** x *** cm. The endocardium is [describe surface and presence of
fibrosis]. Sectioning reveals the myocardium is remarkable for [areas of

Page | 3
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

fibrosis/necrosis/calcification]. Representative sections are submitted [describe

cassette submission].
Cassette Submission: 1-2 cassettes of representative sections

Specimen Type: HEART TRANSPLANT (recipient explant specimen)

Procedure:
1. Discuss the case with the attending before putting the heart in formalin.
2. Photograph the anterior and posterior surfaces; get an x-ray.
3. Weigh and measure the specimen (base to apex; left to right).
4. Provide an external examination with focus on the following:
a. Is the heart dilated?
b. If present, what is the morphology of the atrial appendages?
c. What is the configuration of the great arteries?
d. Are their pericardial adhesions?
e. How much pericardial fat is there?
5. If calcified, the coronary arteries may need to be dissected off before proceeding
(x-ray can help decide this). If decalcification is needed:
a. Dissect the coronary arteries from the heart noting course, size and
dominance of vessels. Remove with any vein or internal mammary grafts.
b. Fix overnight.
c. Decalcify adequately.
d. Cut at 3 mm intervals.
e. Note distribution of lesions and degree of luminal narrowing.
f. Note characteristics of lesions.
g. Photograph.
h. At a minimum, submit regions of maximum narrowing for histologic sections
(LAD, RCA, LCx). If any gross lesions are identified, submit sections of
those too.
i. If grafts are present, submit regions of gross lesions and sites of
anastomosis to coronary arteries (remove sutures if possible).
j. Look out for stents (x-ray can be helpful).
6. Hearts with congenital malformations must be reviewed with the attending
pathologist prior to dissection. For all other hearts, unless otherwise specified:
a. Breadloaf the heart from apex to mid ventricle (3 – 4 transverse slices).
b. Photograph the slices.
c. Open the heart in the direction of blood flow.
d. Photograph any intracardiac lesions if present.
7. The atria and/or appendages may not be included with the specimen, indicate if
absent.

Page | 4
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

8. Describe the individual chambers. Are they dilated? Are the walls thinned? Is
there hypertrophy? Aneurysms?
9. Describe the endocardial surfaces (Note thickening, hemorrhage, mural thrombus,
fibrosis, etc…).
10. Describe the appearance of the cardiac valves. For semilunar valves, note number
of cusps, their thickness, and status of commissures. Note the presence of
calcifications of leaflets or annulus. Examine chordae tendineae for thickening,
shortening, or fusion. Measure valve circumferences.
11. Examine the coronary circulation. Is it right, left, or co-dominant? Is the course
normal or anomalous? Is the course epicardial (normal) or are there areas of
myocardial tunneling. Are the ostia in the normal positions? At least one section of
each major coronary vessel is recommended (LAD, RCA, LCx).
12. If any hardware is present (e.g. ventricular assist device, pacemaker, etc…),
photograph the hardware and note the serial number on the device. Try to be as
specific as possible when describing the device (e.g. “HeartMate II” rather than just
“LVAD”). Sample adherent tissue to evaluate for infection.
13. Every heart is different, so the sections of myocardium you submit may be different
on a case by case basis (discuss with attending). Always sample any focal lesions
in addition to the standard sections, as illustrated below:

Page | 5
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

1. Anteroseptal
2. Anterior
3. Anterolateral
4. Posterolateral
5. Posterior
6. Posteroseptal
7. Right ventricle

Take sections from the mid-ventricle so as to include the papillary muscles. Make
sure sections are transmural (include endocardium and epicardium). The
endocardial side is of particular importance, since most pathology will be
subendocardial. Sampling in this way will help identify which coronary vessel(s)
are involved.
14. For your write-up, list the primary pathologic process (e.g. atherosclerotic
coronary artery/ischemic heart disease, dilated cardiomyopathy, complex
congenital heart disease, etc…) followed by the sequelae of the primary disorder
or secondary findings (e.g. myocardial infarction). List the past procedures and
comment on the presence or absence of any device pathology, if applicable.

Page | 6
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and
received [fresh/in formalin] is a *** gram trans-atrially resected heart measuring *** x ***
x *** cm. [Note: Photograph the heart before and after dissection – demonstrating the
interior surface of the chambers and valves]. The epicardial surface is
[adhesions/smooth/fatty]. The configuration of the great arteries is [normal, abnormal
(describe)]. The atria are [normal size, dilated, hypertrophied]. The foramen ovale is
[closed, patent]. The ventricles are [normal size, dilated, hypertrophied]. The mural
endocardium is [translucent, fibrotic (distribution)]. The valves have the normal number
of leaflets and are free of thrombi, calcification, myxomatous degeneration, and
vegetations [if abnormal, describe]. The chordae tendineae are of [normal length and
thickness, fused, shortened]. The myocardium is [brown and unremarkable, fibrosis,
myocardial infarction]. The coronary ostia are [in the normal position, anomalous
(describe)]. The coronary arteries are [right dominant, left dominant] and have a [normal
epicardial course, anomalous course (describe), intramyocardial course (describe
location, length of intramyocardial component, and depth)]. The right coronary artery is
[patent, calcified, % stenosis]. The left anterior descending coronary artery is [patent,
calcified, % stenosis]. The left circumflex coronary artery is [patent, calcified, stenosis].
[Describe any stents or bypass grafts present].
The heart measurements are as follows:
Tricuspid valve (cm): [circumference]
Pulmonic valve (cm): [circumference]
Mitral valve (cm): [circumference]
Aortic valve (cm): [circumference]
Right ventricular free wall (cm): [wall thickness measured ~1 cm inferior to PV]
Interventricular septum (cm): [wall thickness excluding trabeculae]
Left ventricular free wall (cm): [wall thickness excluding trabeculae]

[Describe any devices present – VAD, pacer wires, etc.]. Representative sections are
submitted in [describe cassette submission noting blocks needing decalcification].

Specimen Type: VENTRICULAR ASSIST DEVICES

PROCEDURE: Review all ventricular assist devices with Dr. G Fishbein.
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and
received [fresh/in formalin] is a [type] ventricular assist device with the serial number
“***”. The inflow cannula is free of thrombi [if not, describe location and size]. [If an
inflow valve is present, describe]. There is no in-pump thrombus [if thrombus present,
describe location and size]. [If an outflow valve is present, describe]. The outflow graft to

Page | 7
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

the aorta is free of thrombi [if not, describe location and size]. The outflow anastomosis
is [present and patent, present with pannus (describe), absent]. The driveline is [intact,
damaged] with [no evidence of infection, infected]. A gross photograph is taken. The
specimen is for gross examination only.

Cassette Submission: No tissue submitted

 Submit one cassette of representative tissue if adherent tissue is
present

Specimen Type: VESSELS

Procedure:
General Comments
1. Measure length, diameter and wall thickness.
2. Note presence of any dilatations or constrictions, zones of swelling or
inflammation.
3. Describe luminal contents, looking especially for thrombi. Lumen is best
evaluated by a series of closely spaced cross sections.
4. Note and sample any areas of hemorrhage, potential dissections, etc…
Atherosclerosis
1. Specimens from endarterectomies and aneurysmectomies for atherosclerosis
are frequently received as fragments of atheroma and some intima.
2. Measure or weigh. Note range of piece sizes.
3. Describe any identifiable vessel wall or thrombus.
4. Submit representative sections of fragments cut perpendicular to the luminal
surface and cross sections of vessels.
5. If vessel is calcified, submit for decalcification.
Varicose veins
1. One block only is usually all that is necessary; describe dilatations, thickening
of walls and/or presence of thrombi.
Arteritis and other arterial lesions
1. Arteries biopsied to rule out vasculitis should be grossed by the histotechs per
protocol, not by PAs or residents.
Grafts
1. All biologic grafts should be submitted for microscopic examination.
2. Synthetic (dacron or Gore-tex) grafts with lesions should also be sampled,
preferably at anastomosis with native vessel.

Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and
received [fresh/in formalin] is a segment of vessel measuring *** cm in length x *** cm in
diameter with a wall thickness of *** cm. The specimen is remarkable for [describe
areas of dilations, constrictions, zones of swelling, inflammation (“tree-barking”)]. The
lumen is remarkable for [describe luminal contents – looking especially for thrombi].
Representative sections are submitted in [describe cassette submission].

Page | 8
 CARDIOVASCULAR PATHOLOGY GROSSING GUIDELINES

Cassette Submission: 1-3 cassettes

 Atherosclerosis: Representative sections to include fragments cut
perpendicular to the luminal surface and cross sections of vessels
o Submit for decalcification if necessary
 Varicose Veins: 1 cassette is sufficient
 Arterial lesions: Serially cross section. Submit 1 representative
cross-section and sections of any focal lesions.
 Grafts: Include section at anastomosis with native vessel

Page | 9