Methods

Because adipose tissue is lighter than cardiac muscle, hearts with enormous quantities of fat tend to float in containers of 10% formaldehyde and often in water.

During 2013 and 2014, Dr. Joseph M. Guileyardo, head of the autopsy service at Baylor University Medical Center, performed a total of 165 autopsies on adults. In 8, the autopsy permit did not allow examination of the heart; in 3 others, the autopsy was in patients who had previous cardiac transplantation. Of the remaining 154 autopsies in adults, WCR examined and described the hearts in 146 (95%). This study is limited to these 146 cases.

The hearts were “cleaned” of extraneous tissues, such as parietal pericardium, and then placed in a container of 10% fresh formaldehyde to determine if the heart floated to the surface after carefully removing any residual air from each chamber by compressing the heart several times when it was submerged. The heart was incised in various fashions depending on the perceived cardiac condition present (or absent) and weighed after gently “patting” all exposed surfaces by paper towels to remove extraneous water or formaldehyde. The scales used were accurate to 0.1 g (Ohaus Scott Pro Scale, Parsippany, New Jersey) or to 1.0 g (Acculab Vicon Digital Scale, Arvada, Colorado). All hearts were weighted by WCR.

The anterior surfaces of many of the 146 hearts were photographed, and, after opening, all hearts were photographed (by JMK). The clinical records were then obtained on each of the 146 patients through Baylor Health Care System’s electronic medical record (Allscripts Sunrise Enterprise, Chicago, Illinois).

Statistical analysis was done using STATA 14.0. The baseline characteristics of patients with floating and nonfloating hearts were compared using the chi-square or Fisher’s exact tests for proportions and t test/Wilcoxon’s rank-sum test for continuous variables where applicable. In addition, comparisons were conducted separately for men and women. Correlations among heart weight, age, and body mass index (BMI) were evaluated using Pearson’s correlation analysis. For correlation analyses, the data were rendered normal by removing any outliers.

Results

The major finding in this study was the high frequency of massive cardiac adiposity (as determined by whether the heart floated in a container of formaldehyde) at necropsy ( Figures 1 to 3 ). Of the 146 hearts, 76 (52%) contained such large quantities of adipose tissue that they floated and 70 (48%) did not float.

Shown here is a 780-g floating heart—anterior view (A) , posterior view (B) , 4-chamber view (C) , and view of the 2 atrial septal bulges from the orifice of the inferior vena cava (D) are shown. The quantity of subepicardial adipose tissue is massive and from the anterior aspect both right and left ventricles are covered by adipose tissue except for an extremely small portion of left ventricle at the apex. The photograph in (B) not only shows the huge quantities of fat on the posterior surface of the ventricles but also in the walls of the atria. The 4-chamber view (C) shows severe fatty infiltration of the atrial septum except for the fossa ovale region (lipomatous hypertrophy of the atrial septum). The coronary system in this patient was co-dominant: the lumens of the right and left circumflex coronary arteries are wide open. The adipose tissue covering the right ventricular wall is thicker than its muscular wall. Neither ventricular cavity is dilated. The 2 bulges shown in (D) are of the atrial septum toward the right atrium. The indentation is the area of the fossa ovale region, which is devoid of adipose tissue. This 64-year-old black woman had undergone sleeve gastrectomy 4 months before death and her BMI just before operation was >50 kg/m ² . Eighteen days after the operation, the BMI was 52 kg/m ² . The patient had diabetes mellitus, systemic hypertension, obstructive sleep apnea, chronic obstructive pulmonary disease, and rheumatoid arthritis.

Shown here is the 490-g floating heart of a 55-year-old white woman who had a laparoscopic Nissen fundoplication operation 6 months before death because of a BMI >40 kg/m ² postoperatively multiple gastrointestinal complications followed. At necropsy, the heart weighed 490 g and floated in a container of 10% formaldehyde. Shown here is the anterior view (A) , posterior view (B) , base of the heart after cutting the cardiac ventricles in several slices parallel to the posterior atrioventricular sulcus (C) , and 4 views of the ventricles (D) caudal to the view shown in (C) . From the anterior aspect, myocardium cannot be seen. The thickness of the adipose tissue covering the right ventricular free wall is thicker than its muscular wall. The left ventricular cavity is not dilated. The right ventricular cavity is dilated.

Shown here is the 830-g floating heart of a 64-year-old white woman whose BMI was 57 kg/m ² . This patient died of acute myocardial infarction involving the apical half of left ventricle and was in severe heart failure for some time. A thrombus developed in the apex of left ventricle. The left ventricular ejection fraction by echocardiogram was 33%. She had severe narrowing of the left anterior descending and left circumflex coronary arteries and stents were placed in both. The anterior surface of the heart (A) , the posterior portion of the heart (B) , a parasagittal view of the right side of the heart showing the right atrium, tricuspid valve, and right ventricular inflow tract (C) , and left parasagittal cut (D) showing the infarct in the apical half of the left ventricular free wall are shown. The quantity of subepicardial adipose tissue is massive. The entire walls of both right and left ventricles are covered by adipose tissue. The right coronary artery shown in (C) is wide open. The thickness of the subepicardial adipose tissue over the right ventricle is thicker than then the right ventricular myocardial wall.

The second finding was comparison of various clinical and morphologic variables in the patients with floating versus nonfloating hearts ( Table 1 ). As shown in the accompanying table, age was the only variable that was significantly different between the 76 patients with floating hearts (62 ± 13 years) and the 70 patients with nonfloating hearts (58 ± 14 years). Women with floating hearts were older (62 ± 13 years) compared with those with nonfloating hearts (52 ± 15 years), whereas no difference in age was noted among men. Comparison of the patients with floating hearts versus nonfloating hearts showed no significant differences in gender, BMI, frequency of systemic hypertension or diabetes mellitus, heart weight, either acute or healed myocardial infarcts or both at necropsy, or whether death was due to coronary or noncoronary disease ( Table 1 ). The mean heart weights were larger in the men than in the women whether the heart floated or did not float.

Figure 4 graphically shows the relation between BMI and heart weight in both floating and nonfloating hearts in both men and women. A weak positive correlation was found. Most hearts were of increased weight (>350 g in women and >400 g in men). Figure 5 graphically shows the relation of heart weight to age in both men and women and also the relation of the 2 variations to whether the heart floated. These relations were negative.

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