Guidelines for autopsy investigation of sudden cardiac death: 2017 update from the Association for European Cardiovascular Pathology

Sudden cardiac death in persons aged 50 years or younger: diagnostic yield of a regional molecular autopsy program using massive sequencing

INTRODUCTION AND OBJECTIVES

Sudden cardiac death (SCD) in young people often has a genetic cause. Consequently, the results of "molecular autopsy" may have important implications for their relatives. Our objective was to evaluate the diagnostic yield of a molecular autopsy program using next-generation sequencing.

METHODS

We performed a prospective study of a cohort of consecutive patients who died from nonviolent SCD, aged ≤ 50 years, and who underwent molecular autopsy using large panels of next-generation sequencing, with subsequent clinical and genetic family screening. We analyzed demographic, clinical, toxicological, and genetic data.

RESULTS

We studied 123 consecutive cases of SCD in persons aged ≤ 50 years. The incidence of SCD was 5.8 cases/100 000 individuals/y, mean age was 36.15±12.7 years, and 95 were men (77%). The cause was cardiac in 53%, unexplained SCD in 24%, toxic in 10.6%, and infant SCD in 4%. Among cardiac causes, ischemic heart disease accounted for 38% of deaths, arrhythmogenic cardiomyopathy for 7%, hypertrophic cardiomyopathy for 5%, and idiopathic left ventricular hypertrophy for 11%. Genetic analysis was performed in 62 cases (50.4%). Genetic variants were found in 42 cases (67.7%), with a mean of 3.4±4 genetic variants/patient, and the variant found was considered to be pathogenic or probably pathogenic in 30.6%. In unexplained SCD, 70% showed some genetic variant. Family screening diagnosed 21 carriers or affected individuals, 5 of whom were at risk, indicating an implantable cardiac defibrillator.

CONCLUSIONS

Protocol-based and exhaustive study of SCD from cardiac causes in persons aged ≤ 50 years is feasible and necessary. In a high percentage of cases, the cause is genetic, indicating the existence of relatives at risk who could benefit from early diagnosis and treatment to avoid complications.

Retrospective Analysis of Sudden Cardiac Deaths in a 10-Year Autopsy Series in the City of Isparta in Turkey

Sudden cardiac death (SCD) is an important public health problem that accounts for approximately 15% to 20% of global deaths. Our retrospective study aimed to analyze etiological distribution and epidemiological data of 128 cases with SCD as death cause based on autopsies between 2010 and 2019. The mean age of SCD cases was 57.09, with the highest incidence in older than 60 years (43.8%). Male/female ratio was 4.5:1, peaking with 9.2:1 in the 41- to 60-year age group. Deaths occurred mostly at home (41.4%). Coronary atherosclerotic heart disease (CAD) was main SCD cause (65.6%) with cardiac tamponade (10.9%), unexplained SCD (8.6%), and hypertrophic cardiomyopathy (7.8%) after it. A total of 71.2% of CAD cases had coronary artery stenosis of greater than 75% and 92.9% had atherosclerotic degeneration in the left anterior descending artery. Based on the body mass index-based normal heart weights table, 91.7% of CAD cases had cardiomegaly. This study showed CAD, cardiomegaly, and high body mass index concurrence as a very important SCD risk. Because SCD incidence increases in older than 40 years, determining risk groups through regular medical examinations and inspections, older than 30 years would provide implementation of preventive measures. Some cardiac diseases causing sudden death are undetectable despite detailed autopsy and histopathological examinations. Including postmortem cardiogenetic analysis among routine techniques in sudden deaths would lower sudden unexplained death diagnosis rates.

Ventricular Weight Increases Proportionally With Total Heart Weight in Postmortem Population

Heart weight is routinely measured at postmortem examination and is critical to determine whether the heart is enlarged (ie, cardiomegaly). Cardiomegaly has the potential to cause sudden death by being electrically unstable, resulting in fatal arrhythmias. The majority of fatal cardiac arrhythmias is ventricular in origin and is assumed that ventricular size is disproportionately larger in cardiomegaly. This prospective study compared ventricular weight (VW) and total heart weight (THW) in 40 consecutive cases. The results, unexpectedly, showed that VW increases proportionally and linearly with THW in normal and enlarged hearts (THW, >500 g) and did not increase disproportionally with increased THW. The ratio of VW/THW did not have any significant correlation or difference with sex, height, weight, and cardiac causes of death but did have a negative correlation with age. Further studies are indicated to document the morphological changes when the heart enlarges, which may aid in understanding the pathophysiology of sudden death from cardiomegaly.

HPO-driven virtual gene panel: a new efficient approach in molecular autopsy of sudden unexplained death

BACKGROUND

Molecular autopsy represents an efficient tool to save the diagnosis in up to one-third of sudden unexplained death (SUD). A defined gene panel is usually used for the examination. Alternatively, it is possible to carry out a comprehensive genetic assessment (whole exome sequencing, WES), which also identifies rare, previously unknown variants. The disadvantage is that a dramatic number of variants must be assessed to identify the causal variant. To improve the evaluation of WES, the human phenotype ontology (HPO) annotation is used internationally for deep phenotyping in the field of rare disease. However, a HPO-based evaluation of WES in SUD has not been described before.

METHODS

We performed WES in tissue samples from 16 people after SUD. Instead of a fixed gene panel, we defined a set of HPO terms and thus created a flexible "virtual gene panel", with the advantage, that recently identified genes are automatically associated by HPO terms in the HPO database.

RESULTS

We obtained a mean value of 68,947 variants per sample. Stringent filtering ended up in a mean value of 276 variants per sample. Using the HPO-driven virtual gene panel we developed an algorithm that prioritized 1.4% of the variants. Variant interpretation resulted in eleven potentially causative variants in 16 individuals.

CONCLUSION

Our data introduce an effective diagnostic procedure in molecular autopsy of SUD with a non-specific clinical phenotype.

Sudden Cardiac Death-A New Insight Into Potentially Fatal Genetic Markers

Sudden cardiac death (SCD) is an unexpected and dramatic event. It draws special attention especially in young, seemingly healthy athletes. Our scientific paper is based on the death of a young, 23-year-old professional footballer, who died on the football field after a two-year history of cardiac symptoms. In this study we analyzed clinical, ECG and laboratory data, as well as results of genetic testing analysis in family members. To elucidate potential genetic etiology of SCD in this family, our analysis included 294 genes related to various cardiac conditions.

Cardiac hypertrophy at autopsy

Since cardiac hypertrophy may be considered a cause of death at autopsy, its assessment requires a uniform approach. Common terminology and methodology to measure the heart weight, size, and thickness as well as a systematic use of cut off values for normality by age, gender, and body weight and height are needed. For these reasons, recommendations have been written on behalf of the Association for European Cardiovascular Pathology. The diagnostic work up implies the search for pressure and volume overload conditions, compensatory hypertrophy, storage and infiltrative disorders, and cardiomyopathies. Although some gross morphologic features can point to a specific diagnosis, systematic histologic analysis, followed by possible immunostaining and transmission electron microscopy, is essential for a final diagnosis. If the autopsy is carried out in a general or forensic pathology service without expertise in cardiovascular pathology, the entire heart (or pictures) together with mapped histologic slides should be sent for a second opinion to a pathologist with such an expertise. Indication for postmortem genetic testing should be integrated into the multidisciplinary management of sudden cardiac death.

Sudden Death and Coronary Artery Anomalies

Congenital coronary artery anomalies (CAA) include a wide spectrum of malformations present at birth with various clinical manifestations and degrees of severity. Patients may be asymptomatic, and CAA may be an incidental finding during cardiac imaging or at autopsy. However, in other cases, ischemia-related signs and symptoms, leading to an increased risk of sudden cardiac death (SCD), often as first presentation may occur. In this chapter, we discuss the normal anatomy of the coronary arteries (CA) and the pathology of CAA at risk of SCD, including our experience with victims of SCD among the young population (age <40 years) and among athletes.

Prevented Sudden Cardiac Death and Neurologic Recovery in Inherited Heart Diseases

Introduction: Inherited cardiovascular diseases are an important cause of sudden cardiac death (SD). The use of risk scores identify high risk patients who would benefit from an implantable cardioverter-defibrillators (ICDs). The development of automated devices for out-of-hospital cardiac arrest improves early resuscitation. The objective of the study is to quantify prevented SD and the neurological recovery of patients with inherited cardiovascular diseases. Methods: Two hundred fifty-seven cases of SD (age 42 ± 18 years, 79.4% men) of non-ischemic cardiac cause were prospectively collected during the study period (2009-17). Fifty three (20.6%) had a resuscitated cardiac arrest (RCA) (age 40 ± 18 years, 64.2% male). Epidemiological, clinical and autopsy aspects were analyzed. Prevented SD was defined as a combination of RCA and appropriate ICD therapy cases. Results: An autopsy was performed in 157/204 (77.0%) cases who died. There were 19 (12.1%) cases with a negative autopsy. The diagnosis of cardiomyopathy and channelopathy was 58.0 and 18.7%, respectively. Female sex and confirmed or suspected channelopathy were associated with successful resuscitation. The percentage of prevented SD remained low during the study period (mean 35.6%). 60.4% of RCA cases presented good neurological outcome. There was no association between neurological recovery and therapeutic hypothermia, but there was association with time of resuscitation (min). Conclusion: A fifth part of non-ischemic cardiac arrests were resuscitated. Female sex and channelopathies were more prevalent among RCA. Two thirds of RCA had a good neurological recovery.

Sudden cardiac death-update

Sudden cardiac death (SCD) is one of the most common causes of death worldwide with a higher frequency especially in the young. Therefore, SCD is represented frequently in forensic autopsy practice, whereupon pathological findings in the heart can explain acute death. These pathological changes may not only include myocardial infarction, coronary thrombosis, or all forms of myocarditis/endocarditis but also rare diseases such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system, or primary cardiac tumours.

Small Vessel Disease: Another Component of the Hypertrophic Cardiomyopathy Phenotype Not Necessarily Associated with Fibrosis

Background: Hypertrophic cardiomyopathy (HCM) is characterized by myocardial disarray, small vessel disease (SVD), and fibrosis. The relationship between SVD and replacement-type fibrosis is still unclear. Methods: Histopathologic assessment of replacement-type fibrosis and SVD in HCM patients with either end-stage heart failure (HF) or sudden cardiac death (SCD). Chronic ischemic heart disease (IHD) patients served as controls. Results: Forty HCM hearts, 10 HF and 30 SCD, were studied. Replacement-type fibrosis was detected in all HF and in 57% of SCD cases. In SCD, replacement-type fibrosis was associated with older age, greater septal thickness, SVD prevalence, and score (all p < 0.05). Prevalence of SVD did not show significant differences among SCD, HF, and IHD (73%, 100% and 95%, respectively), while SVD score was higher in HF than IHD and SCD (2.4, 1.95, and 1.18, respectively) and in areas with replacement-type fibrosis vs. those without in HF (3.4 vs. 1.4) and SCD (1.4 vs. 0.8) (all p < 0.05). Conclusions: SVD is a frequent feature in HCM independent of the clinical presentation. A higher SVD score is observed in HCM-HF and in areas with replacement-type fibrosis. Although SVD is part of the HCM phenotype, further remodeling of the microcirculation might occur secondarily to fibrosis.

[Autopsies are essential for a better knowledge and prevention of sudden cardiac death]

In France, the incidence of sudden cardiac deaths (SCD) is approximately 30,000-50,000 per year. In the whole population, their cause is an atherosclerotic coronary disease in more than 80 % of cases, but in the young (<35 years old), causes are various, including genetic, infectious, toxic, congenital anomalies, immune…Therefore a multidisciplinary approach is required for a better knowledge and prevention of SCD. In this article, we examine different aspects of autopsies and complementary investigations: histopathology, toxicology, biochemistry, genetics and virology. Six cases illustrate the importance of a multidisciplinary approach. There are two categories of autopsies: medicolegal or medical. Medicolegal autopsies are requested by a judicial authority when a death is considered suspicious. These autopsies are performed by forensic doctors. Most of them are not pathologists. During the autopsies, blood and tissue samples are taken, but analyses are done only at the request of the judicial authority if the analyses are useful for the truth. Consequently, the cause of death can remain uncertain. Medical autopsies are performed by a pathologist at the request of a clinician. The family consent is required. Useful analyses are performed, which is essential for the determination of a precise cause of death. In the young, "molecular autopsy", in addition to histology and other analyses, is essential in preventing genetic causes of SCD.

Sudden death in a 39-year-old woman due to three-vessel coronary artery disease: A case report and literature review

Coronary atherosclerosis may be underestimated in previously asymptomatic and apparently healthy young people, although it has been reported in various epidemiological studies. Between 7% and 21% of sudden cardiac deaths in previously asymptomatic people aged <45 years are due to three-vessel coronary artery disease. So, clinical services need to vigilant for this condition. We report a single case of sudden death in a young woman who was affected by three-vessel coronary artery disease. This 39-year-old woman attended an emergency department for non-specific chest pain. After a brief observation period, in the absence of signs of an acute myocardial event, she self-discharged. However, she died suddenly the next day. The subsequent autopsy did not show significant pathological findings, although macroscopic examination of the heart revealed critical three-vessel coronary artery disease. Standard histological examination confirmed an atheromatous plaque obstructing >75% of the lumen of the anterior descending artery, complicated by haemorrhagic phenomena, with diffuse calcified and sub-totally occluded atherosclerotic plaques in the other vascular sections, without ischaemic signs of the cardiomyocytes or fibrosis. When young people present with chest pain, they must be carefully evaluated. Risks need to be clearly explained, particularly when self-discharge is requested.

2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

[Inflammatory cardiomyopathies: Diagnosis, correlations with imaging, interest of myocardial biopsy and place of molecular biology]

Inflammatory cardiomyopathies, also known as "myocarditis" are inflammatory pathologies affecting the myocardium and characterized by vast etiological and clinical heterogeneity. They can be asymptomatic, particularly in viral forms, or be responsible for sudden death, particularly in subjects under 35 years olds. Due to insufficient sensitivity and specificity of imaging and biology, the gold standard is histopathological and is performed on an endomyocardial biopsy or on explanted heart samples in a transplant context. Their classification has considerably evolved and is now based on the identification of a predominant cell pattern such as lymphocytic, neutrophilic or eosinophilic polynuclear, giant cell or granulomatous myocarditis. These different patterns will guide the etiological diagnosis, prognosis and the therapies to be implemented. Due to the importance of viral etiologies, this morphological analysis must be complemented by a virological analysis based on PCR with viral load quantification. In addition, some authors have been able to demonstrate the occurrence of myocarditis in patients with arrhythmogenic cardiomyopathy of genetic origin. The aim of this chapter is to review the current state of knowledge on inflammatory cardiomyopathies and their management.

FIFA Sudden Death Registry (FIFA-SDR): a prospective, observational study of sudden death in worldwide football from 2014 to 2018

OBJECTIVE

To investigate the underlying causes and regional patterns of sudden death in football (soccer) players worldwide to inform and improve existing screening and prevention measures.

METHODS

From 2014 to 2018 cases of sudden cardiac death (SCD), survived sudden cardiac arrest (SCA) and traumatic sudden death were recorded by media monitoring (Meltwater), a confidential web-based data platform and data synchronisation with existing national Sudden Death Registries (n=16). Inclusion criteria were met when sudden death occurred during football-specific activity or up to 1 hour afterwards. Death during other activities was excluded.

RESULTS

A total of 617 players (mean age 34±16 years, 96% men) with sudden death were reported from 67 countries; 142 players (23%) survived. A diagnosis by autopsy or definite medical reports was established in 211 cases (34%). The leading cause in players >35 years was coronary artery disease (76%) and in players ≤35 years was sudden unexplained death (SUD, 22%). In players ≤35 years the leading cause of SCD varied by region: cardiomyopathy in South America (42%), coronary artery anomaly in North America (33%) and SUD in Europe (26%). Traumatic sudden death including commotio cordis occurred infrequently (6%). Cardiopulmonary resuscitation (CPR) resulted in a survival rate of 85% with the use of an automated external defibrillator (AED) compared with 35% without.

CONCLUSIONS

Regional variation in SCD aetiology should be verified by expansion of national registries and uniform autopsy protocols. Immediate access to an AED at training and competition sites, as well as CPR training for players, coaches and staff members, is needed to improve survival from SCA.

Can post-mortem coronary artery calcium scores aid diagnosis in young sudden death?

This study sought to explore the feasibility and utility of post-mortem coronary artery calcium (CAC) scoring in identifying patients with ischemic heart disease as cause of sudden death. 100 deceased patients aged 18-50 years underwent post-mortem examination in the setting of sudden death. At post-mortem, fifty cases were determined to have ischemic heart disease, and fifty had death attributed to trauma or unascertained causes. The CAC score was calculated in a blinded manner from post-mortem CTs performed on all cases. CAC scores were assessable in 97 non-decomposed cases (feasibility 97%). The median CAC score was 88 Agatston units [IQR 0-286] in patients deceased from ischemic heart disease vs 0 [IQR 0-0] in patients deceased from other causes (p < 0.0001). Presence of any coronary calcification differed significantly between ischemic heart disease and non-ischemic groups (adjusted odds ratio 10.7, 95% CI 3.2-35.5). All cases with a CAC score > 100 (n = 22) had ischemic heart disease as the cause of death. Fifteen cases had a CAC score of zero but severe coronary disease at post-mortem examination. Post-mortem CAC scoring is highly feasible. An elevated CAC score in cases 18-50 years old with sudden death predicts ischemic heart disease at post-mortem examination. However, a CAC score of zero does not exclude significant coronary artery disease. Post-mortem CAC score may be considered as a further assessment tool to help predict likely cause of death when there is an objection to or unavailability of post-mortem examination.

[Maternal mortality due to cardiovascular disease in France 2013-2015]

Between 2013 and 2015, cardiovascular diseases became one of the two leading causes of maternal mortality, with 36 deaths (13.7% of maternal deaths). The overall maternal mortality ratio for cardiovascular diseases is 1.5 per 100,000 live births, stable compared to the 2010-2012 period. The etiologies in order of decreasing frequency are: pre-existing cardiomyopathies (n=10), aortic dissections (n=9), peripartum cardiomyopathies (n=6), myocardial infarction (n=4), valvular cardiopathies (n=4). Non-optimal care occurred in 72% of cases, increasing since the previous triennium (50%). Similarly, there is a significant increase in the proportion of preventable deaths (possibly or probably) from 35% to 66%. In women with known cardiovascular disease, the lack of multidisciplinary prepregnancy assessment and pregnancy follow-up is most frequent. In patients with unknown cardiovascular disease, the lack of diagnosis of a cardiac event is the most common failure. Cardiovascular conditions or cardiovascular risk factors should be investigated in early pregnancy in order to monitor and refer women to appropriate maternity hospitals. Recent dyspnea, worsening at the end of pregnancy and postpartum, should suggest a cardiac complication. In presence of chest pain, aortic dissection should be considered with the same degree of emergency as myocardial infarction or pulmonary embolism. Cardiac ultrasonography, chest CT, Nt-proBNP and troponin should be considered in case of chest pain or recent dyspnea. Women with cardiac symptoms should be referred to an emergency department (not necessarily to the local maternity) for a complete cardiovascular check-up.

Findings from machine learning in clinical medical imaging applications - Lessons for translation to the forensic setting

Machine learning (ML) techniques are increasingly being used in clinical medical imaging to automate distinct processing tasks. In post-mortem forensic radiology, the use of these algorithms presents significant challenges due to variability in organ position, structural changes from decomposition, inconsistent body placement in the scanner, and the presence of foreign bodies. Existing ML approaches in clinical imaging can likely be transferred to the forensic setting with careful consideration to account for the increased variability and temporal factors that affect the data used to train these algorithms. Additional steps are required to deal with these issues, by incorporating the possible variability into the training data through data augmentation, or by using atlases as a pre-processing step to account for death-related factors. A key application of ML would be then to highlight anatomical and gross pathological features of interest, or present information to help optimally determine the cause of death. In this review, we highlight results and limitations of applications in clinical medical imaging that use ML to determine key implications for their application in the forensic setting.

Proposal for a harmonized protocol for COVID-19 screening and necropsy in forensic sciences facilities

On 31 December 2019, health authorities in the People's Republic of China informed the World Health Organization of a then limited outbreak of interstitial viral pneumonia, identified at a laboratory in the city of Wuhan. In mid-April 2020 this outbreak of COVID-19 (as the disease has been called) has aggravated and spread worldwide, causing more than 200,000 deaths and affecting especially the United States, Spain, Italy, France and the United Kingdom. Despite the severity of the outbreak, the pathological findings have not been described in detail and there are very few guidelines or protocols for conducting autopsy studies on patients who have died from COVID-19. There are currently very few histopathological case series studies on this disease. In addition, some of these studies have been performed on biopsies or surgical resection pieces from patients in whom disease was subsequently demonstrated or through minimally invasive autopsy protocols. None of the studies offer a detailed necropsy protocol. This document proposes a protocol of action for the institutes of Forensic Medicine facing the current SARS-CoV2 pandemic, which combines protection of worker safety with optimization of tissue collection.

[Sudden cardiac death in women, data from the northern Tunisian sudden cardiac-death registry]

BACKGROUND

Sudden cardiac death is a major public health problem. Epidemiological and clinical differences according to gender have been described in sudden cardiac death. The aim of this study was to examine the gender differences between autopsy findings and circumstance of occurrence associated with sudden cardiac death.

METHODS

We prospectively collected epidemiological and autopsy data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between January 2013 and December 2019. Symptoms preceding death, circadian, weekly and seasonal variations of sudden death were also analyzed.

RESULTS

The study population included 1834 men and 468 women with a mean age of 56.5±14.2 years. All cardiovascular risk factors except smoking were significantly more frequent among women but ischemic heart disease was the most common cause of death in men (51.3 %, versus 28 %, P<0.001). Women were more likely to have a negative macroscopic autopsy than men (34 % versus 23.6 %, P<0.001). Chest pain preceding sudden death was more frequent in male (24 % versus 13.2 %, P<0.001). In contrast, women were more likely to have dyspnea (8.1 % versus 15.6 %, P<0.001). Sudden death in women occurred indoors more often than in men (63.9 % versus 54.5 %, P<0.001) and also more often during night (midnight to 6 am). We also recorded an excess cardiac mortality in winter in both sexes.

CONCLUSIONS

Women had considerably more cardiovascular risk factors and more commonly negative macroscopic autopsy. Death occurred indoors and during night more often than in men.

Autopsy examination in sudden cardiac death: a current perspective on behalf of the Association for European Cardiovascular Pathology

In sudden cardiac death, an autopsy is an essential step in establishing a diagnosis of inherited cardiac disease and identifying families that require cardiac screening. To evaluate aspects of post-mortem practice in Europe, a questionnaire was designed and circulated to both clinical and forensic pathologists. There was a 48% response rate and information was obtained from 17 countries. The results showed a wide variety in the management of sudden cardiac death, with a general tendency towards a lack of thorough investigation. In up to 40% of cases, autopsies were not performed in subjects less than 50 years who may have died from cardiac disease. Reasons for this were lack of finance and lack of interest from police, legal authorities, and doctors. Only 50% of pathologists seem to follow a standard protocol for autopsy examination, apparently due to lack of expertise and/or training. When autopsies were performed, histology and toxicology were almost always taken, genetic studies were generally available and retention of the heart for specialist study was usually permitted. Our results suggest that although the standard of practice is appropriate in many centres, many more cases should have autopsies, especially in sudden deaths in subjects less than 50 years.

Myocarditis is rare in COVID-19 autopsies: cardiovascular findings across 277 postmortem examinations

The COVID-19 pandemic, the result of severe acute respiratory syndrome (SARS)-CoV-2, is a major cause of worldwide mortality with a significant cardiovascular component. While a number of different cardiovascular histopathologies have been reported at postmortem examination, their incidence is unknown, due to limited numbers of cases in any given study. A literature review was performed identifying 277 autopsied hearts across 22 separate publications of COVID-19 positive patients. The median age of the autopsy cohort was 75 and 97.6% had one or more comorbidities. Initial review of the data indicate that myocarditis was present in 20 hearts (7.2%); however, closer examination of additional reported information revealed that most cases were likely not functionally significant and the true prevalence of myocarditis is likely much lower (<2%). At least one acute, potentially COVID-19-related cardiovascular histopathologic finding, such as macro or microvascular thrombi, inflammation, or intraluminal megakaryocytes, was reported in 47.8% of cases. Significant differences in reporting of histopathologic findings occurred between studies indicating strong biases in observations and the need for more consistency in reporting. In conclusion, across 277 cases, COVID-19-related cardiac histopathological findings, are common, while myocarditis is rare.

Recommendations for genetic testing in cardiology: Review of major international guidelines

In recent years, the importance of genetic causes of cardiovascular diseases has been increasingly recognized, as the result of significant advances in molecular diagnosis techniques. This growing knowledge has enabled the identification of new phenotypes and the subclassification of clinical syndromes, impacting the therapeutic approach and genetic counseling offered to affected families. This paper describes the state of the art of genetic testing in the main cardiovascular diseases, aiming to provide a useful tool to help cardiologists and other health professionals involved in the care of individuals with hereditary heart diseases and their families.

Incidence of sudden cardiac death in the young: a systematic review

OBJECTIVE

To summarise studies describing incidence of sudden cardiac death in a general population of young individuals to inform screening policy.

DESIGN

Systematic review.

DATA SOURCES

Database searches of MEDLINE, EMBASE and the Cochrane library (all inception to current) on 29 April 2019 (updated 16 November 2019), and forward/backward citation tracking of eligible studies.

STUDY ELIGIBILITY CRITERIA

All studies that reported incidence of sudden cardiac death in young individuals (12-39 years) in a general population, with no restriction on language or date. Planned subgroups were incidence by age, sex, race and athletic status (including military personnel).

DATA EXTRACTION

Two reviewers independently assessed study eligibility, extracted study data and assessed risk of bias using the Joanna Briggs Institute critical appraisal checklist for prevalence studies.

ANALYSIS

Reported incidence of sudden cardiac death in the young per 100 000 person-years.

RESULTS

38 studies that reported incidence across five continents. We identified substantial heterogeneity in population, sudden cardiac death definition, and case ascertainment methods, precluding meta-analysis. Median reported follow-up years was 6.97 million (IQR 2.34 million-23.70 million) and number of sudden cardiac death cases was 64 (IQR 40-251). In the general population, the median of reported incidence was 1.7 sudden cardiac death per 100 000 person-years (IQR 1.3-2.6, range 0.75-11.9). Most studies (n=14, 54%) reported an incidence between one and two cases per 100 000 person-years. Incidence was higher in males and older individuals.

CONCLUSIONS

This systematic review identified variability in the reported incidence of sudden cardiac death in the young across studies. Most studies reported an incidence between one and two cases per 100 000 person-years.

PROSPERO REGISTRATION NUMBER

CRD42019120563.

Sports-related sudden cardiac death in Spain. A multicenter, population-based, forensic study of 288 cases

INTRODUCTION AND OBJECTIVES

To determine the incidence of sports-related sudden cardiac death in Spain, and to identify the clinical-pathological characteristics, substance abuse, and sports activity associated with this entity.

METHODS

Retrospective, population-based, multicenter study of forensic autopsies conducted in 25 provinces during an 8-year period (2010-2017).

RESULTS

We investigated 288 cases (98.6% occurred in men with a mean age of 43.8±14.4 years). The incidence in the general population was 0.38 cases out of 100 000 inhabitants per year (0.82 among regular athletes), and most cases (54%) occurred in persons aged between 35 and 54 years. The most frequent sports (96% recreational) were cycling (28%), football (18%), and jogging (17%). Death was of cardiovascular origin in 99%. The main causes were ischemic heart disease (63%), cardiomyopathies (21%), and sudden arrhythmic death syndrome (6%). In young people, cardiomyopathies (38%) and ischemic heart disease (30%), present after the age of 20 years, were the most prevalent. The disease was diagnosed during life in 23 cases, relevant clinical antecedents were observed in 30 cases, and cardiovascular risk factors, mainly obesity, in 95 cases. Toxicological analysis detected cardiotoxic substances in 7%, highlighting the association between cannabis and acute ischemic heart disease.

CONCLUSIONS

Sports-related sudden cardiac death in Spain has a very low incidence and affects middle-aged men practicing recreational sports, mainly cycling, football, and jogging. This entity is of cardiovascular origin with early onset of ischemic heart disease. Clinical data and substance abuse should be taken into account to develop preventive strategies.

Mind the gap: Knowledge deficits in evaluating young sudden cardiac death

Sudden cardiac arrest affects around half a million people aged under 50 years old annually, with a 90% mortality rate. Despite high patient numbers and clear clinical need to improve outcomes, many gaps exist in the evidence underpinning patients' management. Domains identifying the greatest barriers to conducting trials are the prehospital and forensic settings, which also provide care to the majority of patients. Addressing gaps in evidence along each point of the cardiac arrest trajectory is a key clinical priority.

Feasibility of postmortem examination in the era of COVID-19 pandemic: the experience of a Northeast Italy University Hospital

With the continuous spreading of SARS-CoV-2 and increasing number of deaths worldwide, the need and appropriateness for autopsy in patients with COVID-19 became a matter of discussion. In fact, in the COVID-19 era protection of healthcare workers is a priority besides patient management. No evidence is currently available about the real risk related to the procedure as well as to the subsequent management of the samples. We herein describe the procedure that has been used to perform the first series of postmortem examinations in the COVID center of the Padua University Hospital, Padua, Italy, after the implementation of an ad hoc operating procedure, to minimize the risk of infection for pathologists and technicians. Provided that the procedure is performed in an adequate environment respecting strict biosafety rules, our data indicate that complete postmortem examination appears to be safe and will be highly informative providing useful insights into the complex disease pathogenesis.

Autopsy in adults with congenital heart disease (ACHD)

The adult congenital heart diseases (ACHD) population is exceeding the pediatric congenital heart diseases (CHD) population and is progressively expanding each year, representing more than 90% of patients with CHD. Of these, about 75% have undergone surgical and/or percutaneous intervention for palliation or correction. Autopsy can be a very challenging procedure in ACHD patients. The approach and protocol to be used may vary depending on whether the pathologists are facing native disease without surgical or percutaneous interventions, but with various degrees of cardiac remodeling, or previously palliated or corrected CHD. Moreover, interventions for the same condition have evolved over the last decades, as has perioperative myocardial preservations and postoperative care, with different long-term sequelae depending on the era in which patients were operated on. Careful clinicopathological correlation is, thus, required to assist the pathologist in performing the autopsy and reaching a diagnosis regarding the cause of death. Due to the heterogeneity of the structural abnormalities, and the wide variety of surgical and interventional procedures, there are no standard methods for dissecting the heart at autopsy. In this paper, we describe the most common types of CHDs that a pathologist could encounter at autopsy, including the various types of surgical and percutaneous procedures and major pathological manifestations. We also propose a practical systematic approach to the autopsy of ACHD patients.

Clinical impact of post-mortem genetic testing in cardiac death and cardiomyopathy

Post-mortem genetic analyses may help to elucidate the cause of cardiac death. The added value is however unclear when a cardiac disease is already suspected or affirmed. Our aim was to study the feasibility and medical impact of post-mortem genetic analyses in suspected cardiomyopathy. We studied 35 patients with cardiac death and suspected cardiomyopathy based on autopsy or clinical data. After targeted sequencing, we identified 15 causal variants in 15 patients (yield 43%) in sarcomeric (n = 8), desmosomal (n = 3), lamin A/C (n = 3) and transthyretin (n = 1) genes. The results had various impacts on families, i.e. allowed predictive genetic testing in relatives (15 families), planned early therapeutics based on the specific underlying gene (5 families), rectified the suspected cardiomyopathy subtype (2 families), assessed the genetic origin of cardiomyopathy that usually has an acquired cause (1 family), assessed the diagnosis in a patient with uncertain borderline cardiomyopathy (1 family), reassured the siblings because of a de novo mutation (2 families) and allowed prenatal testing (1 family). Our findings suggest that post-mortem molecular testing should be included in the strategy of family care after cardiac death and suspected cardiomyopathy, since genetic findings provide additional information useful for relatives, which are beyond conventional autopsy.

Significant Differences in PostMortem Heart Weight Before and After Dissection Using the Short-Axis Dissecting Method

Correctly assessing heart weight can be critical at postmortem examination. The current international guidelines advocate using the short-axis method in dissecting the heart and the heart weighed when the blood is emptied. However, it did not specify at what point the heart should be weighed or how the blood should be emptied. This study compared heart weights at three different time points during the heart examination (immediately after dissecting out of the pericardial sac with blood still in chambers, blood washed/removed from heart chambers without the heart opened, and the heart completely opened, blood emptied, and pad dried). This was to illustrate the variation in measurement and potential errors when the heart is weighed at different time of dissection. The results show that there were statistical and clinical significant differences between the heart weights at each weighing points. We recommend the heart to be completely dissected with any blood and residual washing/rinsing water emptied before being weighed. Although performed in this study, the effect of pad drying the heart on heart weight was not explored and was a limitation in this study.

Genetic variants of uncertain significance: How to match scientific rigour and standard of proof in sudden cardiac death?

In many SCD cases, in particular in pediatric age, autopsy can be completely negative and then a post-mortem genetic testing (molecular autopsy) is indicated. In NGS era finding new/rare variants is extremely frequent and, when only variants of unknown significance are found, molecular autopsy fails to find a cause of death. We describe the emblematic case of the sudden death of a 7-year-old girl. We performed a full-body micro-CT analysis, an accurate autopsy, a serum tryptase test and toxicological tests. Since the only macroscopic abnormality we found was a myocardial bridging (length: 1,1 cm, thickness: 0,5 cm) of the left anterior descending coronary artery, a molecular autopsy has been performed. NGS analysis on victim DNA detected rare variants in DPP6, MYH7, SCN2B and NOTCH1 and segregation analysis was then achieved. On the basis of ACMG/AMP (clinical) guidelines, all the found variants were classified as of unknown significance. In other words, both the macroscopic and genetic anomalies we found were of uncertain significance and then the autopsy failed to find the cause of the death. Our case raises three main discussion points: (a) economical, ethical and legal limitations of genetic investigation; (b) risk that genetic testing does not succeed in finding a certain cause of the death; (c) absence of specific guidelines to face the problem of VUS in forensic cases.

Diagnostic yield of hypertrophic cardiomyopathy in first-degree relatives of decedents with idiopathic left ventricular hypertrophy

AIMS

Idiopathic left ventricular hypertrophy (LVH) is defined as LVH in the absence of myocyte disarray or secondary causes. It is unclear whether idiopathic LVH represents the phenotypic spectrum of hypertrophic cardiomyopathy (HCM) or whether it is a unique disease entity. We aimed to ascertain the prevalence of HCM in first-degree relatives of decedents from sudden death with idiopathic LVH at autopsy. Decedents also underwent molecular autopsy to identify the presence of pathogenic variants in genes implicated in HCM.

METHODS AND RESULTS

Families of 46 decedents with idiopathic LVH (125 first-degree relatives) were investigated with electrocardiogram, echocardiogram exercise tolerance test, cardiovascular magnetic resonance imaging, 24-h Holter, and ajmaline provocation test. Next-generation sequencing molecular autopsy was performed in 14 (30%) cases. Decedents with idiopathic LVH were aged 33 ± 14 years and 40 (87%) were male. Fourteen families (30%) comprising 16 individuals were diagnosed with cardiac disease, including Brugada syndrome (n = 8), long QT syndrome (n = 3), cardiomyopathy (n = 2), and Wolff-Parkinson-White syndrome (n = 1). None of the family members were diagnosed with HCM. Molecular autopsy did not identify any pathogenic or likely pathogenic variants in genes encoding sarcomeric proteins. Two decedents had pathogenic variants associated with long QT syndrome, which were confirmed in relatives with the clinical phenotype. One decedent had a pathogenic variant associated with Danon disease in the absence of any histopathological findings of the condition or clinical phenotype in the family.

CONCLUSION

Idiopathic LVH appears to be a distinct disease entity from HCM and is associated with fatal arrhythmias in individuals with primary arrhythmia syndromes. Family screening in relatives of decedents with idiopathic LVH should be comprehensive and encompass the broader spectrum of inherited cardiac conditions, including channelopathies.

Cardiac arrest at rest and during sport activity: causes and prevention

In the Western Countries, cardiovascular diseases are still the most frequent cause of death, which is often sudden. Sudden death (SD) in the young population occurs at a rate of 1/100 000/year and carries a profound social impact both for the young age of the victims and the unanticipated occurrence. Physical effort is a triggering risk factor, in fact SD occurs three times more frequently in athletes than in non-athletes. The screening for sport activity fitness can identify apparently healthy subjects carrying a silent abnormality able to trigger sudden cardiac death during sport activity, thus the fitness screening could be lifesaving. The spectrum of cardiovascular conditions identified at post-mortem examination is quite extensive, and include: coronary, myocardial, valvular diseases, as well as conduction system abnormalities. In 20% of the cases, the heart is normal, and sudden cardiac death is ascribed to ionic channel disease. The diagnosis of cardiomyopathy is possible with the integration of electrocardiogram and echography, thus decreasing significantly the occurrence of SD of athletes in Italy, but early diagnosis of coronary artery disease still remains challenging. The best strategy to further decrease sudden cardiac death during sport activities consists in combining early diagnosis with widespread availability of defibrillators on site.

Cardiovascular Remodeling Experienced by Real-World, Unsupervised, Young Novice Marathon Runners

Aims

Marathon running is a popular ambition in modern societies inclusive of non-athletes. Previous studies have highlighted concerning transient myocardial dysfunction and biomarker release immediately after the race. Whether this method of increasing physical activity is beneficial or harmful remains a matter of debate. We examine in detail the real-world cardiovascular remodeling response following competition in a first marathon.

Methods

Sixty-eight novice marathon runners (36 men and 32 women) aged 30 ± 3 years were investigated 6 months before and 2 weeks after the 2016 London Marathon race in a prospective observational study. Evaluation included electrocardiography, cardiopulmonary exercise testing, echocardiography, and cardiovascular magnetic resonance imaging.

Results

After 17 weeks unsupervised marathon training, runners revealed a symmetrical, eccentric remodeling response with 3-5% increases in left and right ventricular cavity sizes, respectively. Blood pressure (BP) fell by 4/2 mmHg (P < 0.01) with reduction in arterial stiffness, despite only 11% demonstrating a clinically meaningful improvement in peak oxygen consumption with an overall non-significant 0.4 ml/min/kg increase in peak oxygen consumption (P = 0.14).

Conclusion

In the absence of supervised training, exercise-induced cardiovascular remodeling in real-world novice marathon runners is more modest than previously described and occurs even without improvement in cardiorespiratory fitness. The responses are similar in men and women, who experience a beneficial BP reduction and no evidence of myocardial fibrosis or persistent edema, when achieving average finishing times.

Left ventricular hypertrophy is associated with overexpression of HSP60, TLR2, and TLR4 in the myocardium

Left ventricular hypertrophy is a common adaptive response to increased cardiac workload. Cardiomyocytes growth and increase in contractile force are conditioned by sufficient energy production, which implies appropriate mitochondrial function. The 60 kDa heat shock protein (HSP60) is a chaperone essential for mitochondrial proteostasis, but when translocates from mitochondria, it can also act as a potent inflammatory mediator binding to toll-like receptors (TLRs). In this study, we aimed to compare the expression pattern of HSP60, TLR2, and TLR4 in hypertrophic vs non-hypertrophic, normal human myocardium. We further examined whether HSP60 in situ binds to TLRs in hypertrophic myocardial tissue. In addition, expression of activated downstream targets of TLR 2/4 pathways was also evaluated.For this purpose, immunohistochemical expression analyses were performed on myocardial tissue samples obtained during the autopsy of human subjects in which left ventricular hypertrophy was the only cardiopathological finding and had died from sudden cardiac death, as well as from the subjects without any cardiac pathology, that died by unnatural death (accident or suicide). Double immunofluorescence was used to examine HSP60 translocation, while proximity ligation assay (PLA) was performed to assess HSP60 and TLRs interactions.Hypertrophic myocardium showed significantly higher expression of HSP60, TLR2, and TLR4 compared to normal myocardium. Furthermore, in hypertrophic cardiomyocytes, we found membrane translocation of HSP60 and signs of HSP60/TLR interactions.Conclusion: The obtained data point to an important supportive role of HSP60 in adaptive cardiomyocytes growth, while concomitant induction of TLR2 and TLR4 candidates HSP60-TLRs interactions as an early events during pathogenesis of secondary complications consequently to the left ventricular hypertrophy.

Non-diagnostic autopsy findings in sudden unexplained death victims

BACKGROUND

Several inherited cardiac diseases may lead to sudden cardiac death (SCD) a devastating event in the families. It is crucial to establish a post mortem diagnosis to facilitate relevant work-up and treatment of family members. Sudden unexplained death (SUD) victims constitute roughly one third of all SCD cases in Denmark.

METHODS

This was a single center, retrospective study investigating SUD cases. Victims who died unexplained due to suspected or confirmed cardiac disease were consecutively referred to a third line referral center established in 2005. All autopsy reports were investigated. Victims were divided into two groups: non-diagnostic cardiac findings and normal cardiac findings. None of the included victims had findings consistent with a diagnosis based on existing criteria.

RESULTS

In total, 99 SUD cases were referred. The mean age of the victims was 37 years (range 0-62 years, 75% males). A total of 14 (14%) victims had a cardiovascular diagnosis pre-mortem. Thirty-seven cases had normal cardiac findings and non-diagnostic cardiac findings were found in 62 cases (63%). The five most common findings included ventricular hypertrophy and/or enlarged heart (n = 35, 35%), coronary atheromatosis (n = 31, 31%), myocardial fibrosis (n = 19, 19%), dilated chambers (n = 7, 7%) and myocardial inflammation (n = 5, 5%).

CONCLUSION

One third of SUD victims had normal cardiac findings and non-diagnostic cardiac findings were seen in almost two thirds of the SUD victims. These non-diagnostic findings may be precursors or early markers for underlying structural cardiac disorders or may be innocent bystanders in some cases. Further studies and improved post-mortem examination methods are needed for optimization of diagnostics in SUD.

Diagnosis of myocardial infarction at autopsy: AECVP reappraisal in the light of the current clinical classification

Ischemic heart disease is one of the leading causes of morbidity and death worldwide. Consequently, myocardial infarctions are often encountered in clinical and forensic autopsies, and diagnosis can be challenging, especially in the absence of an acute coronary occlusion. Precise histopathological identification and timing of myocardial infarction in humans often remains uncertain while it can be of crucial importance, especially in a forensic setting when third person involvement or medical responsibilities are in question. A proper post-mortem diagnosis requires not only up-to-date knowledge of the ischemic coronary and myocardial pathology, but also a correct interpretation of such findings in relation to the clinical scenario of the deceased. For these reasons, it is important for pathologists to be familiar with the different clinically defined types of myocardial infarction and to discriminate myocardial infarction from other forms of myocardial injury. This article reviews present knowledge and post-mortem diagnostic methods, including post-mortem imaging, to reveal the different types of myocardial injury and the clinical-pathological correlations with currently defined types of myocardial infarction.

Second opinion system for sudden cardiac death cases in forensic practice

Sudden cardiac death (SCD) represents a considerable percentage of cardiovascular deaths worldwide. The most frequent pathological substrate of SCD is atherosclerotic coronary artery disease (CAD). The other, less common, pathologies which can cause SCD include cardiomyopathies, congenital diseases (including abnormal anatomy), and arrhythmias such as channelopathies, many of which are genetically determined. Autopsies of SCD victims are generally performed by forensic pathologists. In some cases, a third person responsibility could be invoked. While CAD diagnosis at post-mortem examination is not a major challenge for the forensic pathologist, the other rarer diseases may be. In such instances, referral of the hearts to specialized centers with recognized expertise is recommended, and this is particularly important in cases of SCDs of young people. Moreover, in order to avoid the frequent overdiagnosis of a pathological heart, an expert opinion should be sought for even in the presence of a morphologically normal heart. In cases where retention of the heart is not feasible, it is essential to provide an extensive photographic documentation, with the indication of the sampling sites for histological examination. However, some practical aspects, as the criteria for case selection in routine forensic practice are missing. In this paper, we present the recommendations for heart retention for a second expert opinion and the alternative of documentation and sampling for cases where retention is not possible.

Systematic Review of the Genetics of Sudden Unexpected Death in Epilepsy: Potential Overlap With Sudden Cardiac Death and Arrhythmia-Related Genes

Background Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death. SUDEP shares many features with sudden cardiac death and sudden unexplained death in the young and may have a similar genetic contribution. We aim to systematically review the literature on the genetics of SUDEP. Methods and Results PubMed, MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus were searched through April 4, 2017. English language human studies analyzing SUDEP for known sudden death, ion channel and arrhythmia-related pathogenic variants, novel variant discovery, and copy number variant analyses were included. Aggregate descriptive statistics were generated; data were insufficient for meta-analysis. A total of 8 studies with 161 unique individuals were included; mean was age 29.0 (±SD 14.2) years; 61% males; ECG data were reported in 7.5% of cases; 50.7% were found prone and 58% of deaths were nocturnal. Cause included all types of epilepsy. Antemortem diagnosis of Dravet syndrome and autism (with duplication of chromosome 15) was associated with 11% and 9% of cases. The most frequently detected known pathogenic variants at postmortem were in Na+ and K+ ion channel subunits, as were novel potentially pathogenic variants (11%). Overall, the majority of variants were of unknown significance. Analysis of copy number variant was insignificant. Conclusions SUDEP case adjudication and evaluation remains limited largely because of crucial missing data such as ECGs. The most frequent pathogenic/likely pathogenic variants identified by molecular autopsy are in ion channel or arrhythmia-related genes, with an ≈11% discovery rate. Comprehensive postmortem examination should include examination of the heart and brain by specialized pathologists and blood storage.

The yield of postmortem genetic testing in sudden death cases with structural findings at autopsy

Sudden cardiac death (SCD) is often associated with structural abnormalities of the heart during autopsy. This study sought to compare the diagnostic yield of postmortem genetic testing in (1) cases with structural findings of uncertain significance at autopsy to (2) cases with autopsy findings diagnostic of cardiomyopathy. We evaluated 57 SCD cases with structural findings at cardiac autopsy. Next-generation sequencing using a panel of 77 primary electrical disorder and cardiomyopathy genes was performed. Pathogenic and likely pathogenic variants were classified using American College of Medical Genetics (ACMG) consensus guidelines. In 29 cases (51%) autopsy findings of uncertain significance were identified whereas in 28 cases (49%) a diagnosis of cardiomyopathy was established. We identified a pathogenic or likely pathogenic variant in 10 cases (18%); in 1 (3%) case with non-specific autopsy findings compared with 9 (32%) cases with autopsy findings diagnostic of cardiomyopathy (p = 0.0054). The yield of genetic testing in SCD cases with autopsy findings consistent with cardiomyopathy is comparable with the yield in cardiomyopathy patients that are alive. Genetic testing in cases with findings of uncertain significance offers lower clinical utility than in cardiomyopathy, with lower yields than detected previously. This highlights the need for stringent evaluation of variant pathogenicity.