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Cohle SD, Wygant CM. Lesions of the Cardiac Conduction System and Sudden Death. Am J Forensic Med Pathol 2024; 45:3-9. [PMID: 37994486 DOI: 10.1097/paf.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
ABSTRACT When a young previously healthy person dies suddenly, occasionally, the scene is noncontributory and the autopsy and drug screen are negative. In such cases, additional studies, including genetic assessment and cardiac conduction system examination, should be performed. We performed a literature search and reviewed our own material to identify possible or definite conduction system anomalies that may cause death. We identified intrinsic conduction system disease including cystic tumor of the atrioventricular node, atrioventricular node (cystic tumor of the AV node), and fibromuscular dysplasia of the atrioventricular node artery to be likely causes of death. Extrinsic causes, in which a generalized disease affects the conduction system, include tumors, autoimmune disease, infiltrative disorders, and others, are a second category of diseases that can affect the conduction system and cause atrioventricular block and sudden death.
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Affiliation(s)
- Stephen D Cohle
- From the Department of Pathology and Laboratory Medicine, Corewell Health, Grand Rapids, MI
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Brahim O, Mahjoub Y, Boussaid M, Limem H, Aissaoui A. Fibromuscular dysplasia of the coronary arteries: An unusual case of sudden death and review of the literature. J Forensic Leg Med 2024; 102:102633. [PMID: 38241822 DOI: 10.1016/j.jflm.2023.102633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 01/21/2024]
Abstract
Fibromuscular dysplasia of the coronary is an uncommon coronary defect with a range of pathological alterations and unpredictable clinical description that can cause sudden death. We present an autopsy case of sudden cardiac death due to a rupture of a coronary artery aneurysm in a 59-year-old woman. Postmortem autopsy revealed two huge saccular aneurysms located at the right coronary artery, one of which was ruptured leading to a fatal hemopericardium. Histopathological examination revealed coronary artery fibromuscular dysplasia with fibromyxoid dissociation of the media causing saccular aneurysms. The involvement of coronary arteries in fibromuscular dysplasia with aneurysmal features has been rarely reported in the literature and is most likely an underdiagnosed finding. Due to the little number of published studies, the etiology is not fully understood and data on pathogenesis, risk factors, manifestation, disease course, and mortality are still unclear, which is a gap that needs to be filled in order to avoid under-diagnosis of the disease. Our case report aimed to discuss the mechanisms of sudden death attributed to coronary fibromuscular dysplasia.
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Affiliation(s)
- Oumeima Brahim
- Department of Legal Medicine, Taher Sfar Teaching Hospital, 5100, Mahdia, Tunisia; Faculty of Medicine of Monastir, University of Monastir, Tunisia; Laboratory of Technology and Medical Imaging " LR12ES06, Tunisia.
| | - Yosra Mahjoub
- Department of Legal Medicine, Taher Sfar Teaching Hospital, 5100, Mahdia, Tunisia; Faculty of Medicine of Monastir, University of Monastir, Tunisia; Laboratory of Technology and Medical Imaging " LR12ES06, Tunisia.
| | - Marwa Boussaid
- Department of Legal Medicine, Taher Sfar Teaching Hospital, 5100, Mahdia, Tunisia; Faculty of Medicine of Monastir, University of Monastir, Tunisia; Laboratory of Technology and Medical Imaging " LR12ES06, Tunisia.
| | - Hiba Limem
- Department of Legal Medicine, Taher Sfar Teaching Hospital, 5100, Mahdia, Tunisia; Faculty of Medicine of Monastir, University of Monastir, Tunisia; Laboratory of Technology and Medical Imaging " LR12ES06, Tunisia.
| | - Abir Aissaoui
- Department of Legal Medicine, Taher Sfar Teaching Hospital, 5100, Mahdia, Tunisia; Faculty of Medicine of Monastir, University of Monastir, Tunisia; Laboratory of Technology and Medical Imaging " LR12ES06, Tunisia.
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Markwerth P, Bajanowski T, Tzimas I, Dettmeyer R. Sudden cardiac death-update. Int J Legal Med 2021; 135:483-495. [PMID: 33349905 PMCID: PMC7751746 DOI: 10.1007/s00414-020-02481-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- P Markwerth
- Institute for Forensic Medicine, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.
| | - T Bajanowski
- Institute for Forensic Medicine, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - I Tzimas
- Institute for Forensic Medicine, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - R Dettmeyer
- Institute for Forensic Medicine, University Hospital Gießen, Giessen, Germany
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Tan SY, Fritsch MK, White S, Arva NC. Dissecting the Cardiac Conduction System: Is It Worthwhile? Pediatr Dev Pathol 2020; 23:413-423. [PMID: 32755444 DOI: 10.1177/1093526620944756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pathologic examination of conduction system (CS) is not routinely performed, and histologic changes are mostly reported in forensic practice. METHODS We studied the value of dissecting the CS in a cohort of pediatric patients with unexplained sudden death or severe, inexplicable arrhythmias. Histopathologic changes present in CS components were recorded and correlated with findings noted in other cardiac structures. RESULTS Twenty-one subjects (11 unexplained sudden deaths and 10 life-threatening arrhythmias) were identified; 18 (86%) had CS pathologic abnormalities. In 13 patients (62%), the CS findings mirrored those found in other cardiac sections (inflammation, allograft vasculopathy, vascular fibromuscular dysplasia, cardiomyopathy-related changes, and tumor/tumor-like conditions). Five cases (24%) had abnormalities restricted to CS (bundle of His [BH] with fibrotic scar and patch material following ventricular septal defect repair, inflammation, BH with fibrosis and calcifications, and intimal fibroplasia of sinoatrial node artery). CONCLUSIONS Pathologic changes within the CS are present in a high number of pediatric patients presenting with unexplained sudden death or life-threatening arrhythmias. Frequently, the findings mirror those observed in other cardiac structures. However, in a significant number of cases (24%), the changes are restricted to CS and likely explain the patients' symptoms or cause of death, suggesting that systematic dissection of CS unveils valuable information.
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Affiliation(s)
- Serena Y Tan
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael K Fritsch
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Steven White
- British Columbia Coroners Service, Vancouver, British Columbia, Canada
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Abstract
This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD) which was commissioned by the Working Group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.
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Arrhythmogenic Ventricular Cardiomyopathy Associated With Fibromuscular Dysplasia of Ostial Right Main Coronary Artery. Am J Forensic Med Pathol 2019; 40:183-187. [PMID: 30844837 DOI: 10.1097/paf.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this article, we report the autopsy findings of a 23-year-old woman, who was found unconscious at home by her relatives. During the transportation to the hospital, the woman was handed over to the ambulance personnel, who were the first to provide cardiopulmonary resuscitation. In the hospital, after an hour-lasting asystole, the heart activity was restored. Prolonged cardiac arrest led to hypoxic brain injury, which resulted in a persistent coma. Examinations carried out during hospitalization detected hypokinetic interventricular septum, frequent ventricular extrasystoles and ventricular fibrillation. The patient died within 35 hours of admission to the hospital. Gross findings of the heart included a noticeable increase of the adipose tissue in the right ventricular wall, where histologically focal myocardial atrophy with focal transmural lipomatosis reaching endocardium were detected. Death was attributed to arrhythmogenic ventricular cardiomyopathy. Pathogenic variants in JUP gene and KCNH2 gene confirmed the diagnosis. Other finding of note was fibromuscular dysplasia of ostial right main coronary artery causing a significant luminal narrowing.
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Gornik HL, Persu A, Adlam D, Aparicio LS, Azizi M, Boulanger M, Bruno RM, de Leeuw P, Fendrikova-Mahlay N, Froehlich J, Ganesh SK, Gray BH, Jamison C, Januszewicz A, Jeunemaitre X, Kadian-Dodov D, Kim ESH, Kovacic JC, Mace P, Morganti A, Sharma A, Southerland AM, Touzé E, van der Niepen P, Wang J, Weinberg I, Wilson S, Olin JW, Plouin PF. First International Consensus on the diagnosis and management of fibromuscular dysplasia. Vasc Med 2019; 24:164-189. [DOI: 10.1177/1358863x18821816] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group ‘Hypertension and the Kidney’ of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.
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Affiliation(s)
- Heather L Gornik
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center and UH Harrington Heart and Vascular Institute, Cleveland, OH, USA
| | - Alexandre Persu
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - David Adlam
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Lucas S Aparicio
- Hypertension Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Michel Azizi
- Paris Descartes University, Paris, France
- Assistance-Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- Institut national de la santé et de la recherche médicale, Centre d’Investigation Clinique 1418, Paris, France
| | - Marion Boulanger
- Normandie Université, UNICAEN, Inserm U1237, CHU Caen Normandie, Caen, France
| | - Rosa Maria Bruno
- Department of Clinical and Experimental Medicine University of Pisa, Pisa, Italy
| | - Peter de Leeuw
- Department of Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Natalia Fendrikova-Mahlay
- Department of Cardiovascular Medicine, Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - James Froehlich
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Santhi K Ganesh
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Bruce H Gray
- University of South Carolina School of Medicine/Greenville, Greenville, SC, USA
| | - Cathlin Jamison
- Association belge de patients atteints de Dysplasie Fibromusculaire/FMD Groep België (FMD-Be), Brussels, Belgium
| | | | - Xavier Jeunemaitre
- APHP, Department of Genetics and Centre for Rare Vascular Diseases, Hôpital Européen Georges Pompidou, Paris, France
- INSERM, U970 – PARCC, University Paris Descartes, Sorbonne Paris
Cité, Paris, France
| | - Daniella Kadian-Dodov
- Zena and Michael A Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Esther SH Kim
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason C Kovacic
- Zena and Michael A Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pamela Mace
- Fibromuscular Dysplasia Society of America (FMDSA), North Olmsted, OH, USA
| | - Alberto Morganti
- Centro Fisiologia Clinica e Ipertensione, Policlinico Hospital, University of Milan, Milan, Italy
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine Division, University of Virginia, Charlottesville, VA, USA
| | | | - Emmanuel Touzé
- Normandie Université, UNICAEN, Inserm U1237, CHU Caen Normandie, Caen, France
| | - Patricia van der Niepen
- Department of Nephrology & Hypertension Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Jiguang Wang
- Shanghai Institute of Hypertension and Center for Epidemiological Studies and Clinical Trials, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ido Weinberg
- Vascular Medicine Section and Vascular Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Scott Wilson
- Monash University (Central Clinical School of Medicine), Melbourne, VIC, Australia
- Department of Renal Medicine, Alfred Health, Melbourne, VIC, Australia
| | - Jeffrey W Olin
- Zena and Michael A Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pierre-Francois Plouin
- Paris Descartes University, Paris, France
- Assistance-Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- Institut national de la santé et de la recherche médicale, Centre d’Investigation Clinique 1418, Paris, France
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Kawashima T, Sato F. Clarifying the anatomy of the atrioventricular node artery. Int J Cardiol 2018; 269:158-164. [DOI: 10.1016/j.ijcard.2018.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 12/12/2022]
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Sudden Death Due to Cystic Tumor of the Atrioventricular Node and Fibromuscular Dysplasia Involving Branches of the Coronary Arteries. Am J Forensic Med Pathol 2017; 39:46-49. [PMID: 29095703 DOI: 10.1097/paf.0000000000000356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this paper, we report the autopsy findings of a 42-year-old White male who was found deceased at his home by his brother in the early morning hours with a history of excessive alcohol consumption 1 day before his death. A medical record review revealed chronic alcohol use with alcohol dependence syndrome, hypertension, and cardiac arrhythmias by electrocardiogram 2 years prior. External examination revealed only a single bruise on the forehead. Internal examination revealed changes associated with chronic alcohol abuse and mild atherosclerosis. The lack of a cause of death at autopsy resulted in a dissection of the cardiac conduction system and the detection of a small cystic lesion at the atrioventricular node region. Microscopic examination revealed a cystic tumor of the atrioventricular node and fibromuscular dysplasia of the coronary artery branches near the sinoatrial and atrioventricular nodes. Based on the case history and autopsy findings, death was attributed to a fatal cardiac arrhythmia due to cystic tumor of the atrioventricular node with fibromuscular dysplasia of the coronary artery branches near the sinoatrial and atrioventricular nodes a possible contributing factor.
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Ottaviani G, Buja LM. Anatomopathological changes of the cardiac conduction system in sudden cardiac death, particularly in infants: advances over the last 25 years. Cardiovasc Pathol 2016; 25:489-499. [PMID: 27616614 DOI: 10.1016/j.carpath.2016.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/04/2016] [Accepted: 08/23/2016] [Indexed: 02/08/2023] Open
Abstract
Sudden cardiac death (SCD) is defined as the unexpected death without an obvious noncardiac cause that occurs within 1 h of witnessed symptom onset (established SCD) or within 24 h of unwitnessed symptom onset (probable SCD). In the United States, its incidence is 69/100,000 per year. Dysfunctions of the cardiac conduction and autonomic nervous systems are known to contribute to SCD pathogenesis, even if most clinicians and cardiovascular pathologists lack experience with detailed examination of the cardiac conduction system and fail to recognize lesions that are crucial to explain the SCD itself. In this review, we sought to describe the advances over the last 25 years in the study of the anatomopathological changes of the conducting tissue, in SCD, in mature hearts and particularly in sudden infant death syndrome (SIDS) and sudden intrauterine unexpected death syndrome (SIUDS), through the articles published in our journal Cardiovascular Pathology (CVP). We carried out an extensive Medline search to retrieve and review all articles published in CVP in which the sudden unexpected death of one or more subjects believed healthy was reported, especially if associated with lesions of the conducting tissue in settings that revealed no other explained causes of death, particularly in infants and fetuses. The cardiac conduction findings of resorptive degeneration, His bundle dispersion, Mahaim fibers, cartilaginous meta-hyperplasia, persistent fetal dispersion, left-sided His bundle, septation of the bifurcation, atrioventricular node dispersion, sinus node hypoplasia, Zahn node, His bundle hypoplasia, atrioventricular node, and His bundle dualism were similarly detected in SIDS and SIUDS victims.
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Affiliation(s)
- Giulia Ottaviani
- "Lino Rossi" Research Center for the Study and Prevention of Unexpected Perinatal Death and Sudden Infant Death Syndrome (SIDS), Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Milan, Italy; Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - L Maximilian Buja
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Zack F, Rodewald AK, Blaas V, Büttner A. Histologic spectrum of the cardiac conducting tissue in non-natural deaths under 30 years of age: an analysis of 43 cases with special implications for sudden cardiac death. Int J Legal Med 2015; 130:173-8. [PMID: 26526026 DOI: 10.1007/s00414-015-1287-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/23/2015] [Indexed: 11/25/2022]
Abstract
In the past, histological findings of the cardiac conduction system or its adjacent structures, such as filiform fibers at the transition from bundle of His to bundle branches, connective tissue at the apex of the ventricular septum, or fibromuscular alterations of the arteries has been considered as a cause of death. However, the prevalence of such findings in a healthy population has been rarely analyzed systematically. In the present study, the morphology of the cardiac conduction system of 43 heart-healthy individuals who died of non-natural causes (ages 0 to 30 years) was investigated. In a high percentage of cases, connective tissue at the apex of the ventricular septum (97.7%), filiform fibers at the transition from bundle of His to the bundle branches (27.9%), and fibromuscular proliferations of the sinoatrial node artery (41.9%), and the AV-node artery (39.5%) could be detected. Based on our observations, these alterations should not be considered as a pathologic entity or as a cause of death.
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Affiliation(s)
- Fred Zack
- Rostock University Medical Center, Rostock, Germany
| | | | - Verena Blaas
- Rostock University Medical Center, Rostock, Germany
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Affiliation(s)
- Sarah C O'Connor
- Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH
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