Postmortem heart weight modelled using piecewise linear regression in 27,645 medicolegal autopsy cases

A statistical study of postmortem heart weight in Chinese adults

INTRODUCTION

Objective assessment of cardiac hypertrophy in forensic pathology practice is of great significance for forensic pathologists, for whom reference values for normal heart weights are needed. Developed regions such as Europe, the United States, and Japan recalculate the weight of human organs at regular intervals, but in China, there has been no systematic calculation of the weights of human organs since 2006.

AIMS

To statistically analyse the heart weight of Chinese adults postmortem and obtain a reference range.

MATERIALS AND METHODS

4170 adult autopsy reports were collected from 12 forensic departments in 10 provinces in China. The causes of death were classified by sex, and heart weight and the heart weight/body height ratio reference values were further calculated according to different body mass index and body heights. Finally, the cutoff value of cardiac hypertrophy in Chinese adults was calculated.

RESULTS

In the group of non-cardiovascular disease causes of death, the cardiac weight of the electric death group was higher, while the heart weight of the prolonged bed-rest group was significantly reduced. After the electric death and prolonged bed-rest groups were excluded, heart weight, the heart weight/body height ratio, and cutoff values for cardiac hypertrophy were further classified and analysed according to body mass index. The mean reference values for heart weight in men and women with normal weight status were 325.82 ± 41.60 g and 286.39 ± 44.84 g, and the heart weight/body height ratios were 1.95 ± 0.23 in men and 1.82 ± 0.27, respectively. The cutoff values for cardiac hypertrophy were 387.35 g for men and 346.80 g for women.

CONCLUSION

The heart weight reference values of both sexes in this study were significantly higher than those in 2006, which is considered related to the development of China's economy and the improvement of people's living standards. This study also suggests the need for a new round of statistical surveys and updated data on the weight of other organs.

Sudden death related to sexual activity: A multicenter study based on forensic autopsies (2010-2021)

INTRODUCTION AND OBJECTIVES

To investigate the epidemiological characteristics, clinic-pathological findings and recent use of substances of abuse and prescribed drugs in sexual activity-related sudden death (SArSD).

METHODS

Multicenter population-based study on forensic autopsies conducted in 27 provinces of Spain over 12 years (2010-2021).

RESULTS

Out of 18046 autopsied natural deaths, 64 cases (0.35 %) of SArSD were investigated (87 % males). Women were younger than males (50.5 ± 13.4 years vs 37.2 ± 14.2; p = 0.017). Sudden cardiac deaths (SCD) accounted for 87 % of cases. Ischemic heart disease was the predominant pathology (58 %), mainly affecting men ≥ 36 years of age. Cerebral haemorrhage (8 %) and asthma (5 %) were the leading non-cardiac causes. In young adults, SADS (36 %) and asthma (27 %) were the main causes The disease responsible of SCD was diagnosed in life in 7 subjects. In 64 % there were cardiovascular risk factors, mainly obesity. Toxicological analysis detected illicit drugs (23 %), mainly cocaine, medications for erectile dysfunction (9 %), and ethanol ≥ 0.5 g/L (8 %). Deaths occurred usually in the context of heterosexual intercourse and during or immediately after sexual activity. The most common location was at home (63 %). In 12 men the sexual partner was a sex worker.

CONCLUSIONS

SArSD has a low incidence in the general population affecting middle-aged males during intercourse with a heterosexual partner. It is of cardiovascular origin, mainly due to ischemic heart disease that frequently remained silent during life. There is a frequent association with obesity, use of cocaine (and, to a lesser extent, medications for erectile dysfunction) and performing unconventional sexual practices. Forensic investigation is useful for developing prevention strategies.

Binucleated Myocytes and Heart Weight: A Preliminary Study Linking Cardiac Hypertrophy and Myocyte Hypertrophy

ABSTRACT

Hypertrophy of the heart is assessed by heart weight (and dimensions) and myocyte hypertrophy. Establishing an association between the two may be useful in assessing hypertrophy in cases where there are limitations in assessing the heart weight. This preliminary study explored the association between the number of binucleated myocytes (a feature of myocyte hypertrophy) in a randomly chosen single high-power field of the left ventricular free wall and heart weight in an adult White population. It also compared the number of binucleated myocytes between cases with increased heart weight (>400 g in female and >500 g in male) and cases with normal heart weight. Heart weight and number of binucleated myocytes correlated significantly in male only. Increased heart weight had a significantly higher number of binucleated myocytes, with 8.5 binucleated myocytes being able to segregate cases with increased heart weight (74% sensitivity and 79% specificity). The results of this study showed the number of binucleated myocytes may have a complementary role in assessing hypertrophy of the heart.

Cardiac Enlargement in a Medicolegal Autopsy Setting

ABSTRACT

A key element for diagnosing cardiac enlargement in an autopsy setting is relevant heart weight references. However, most available references are to a large extent not representative of a medicolegal autopsy population, implying that reference weights are likely lower than those in the relevant population.To establish more applicable heart weight references in a medicolegal autopsy population, we designed a heart weight model that accounts for undiagnosed cardiac enlargement using data from 11,897 nontraumatic Swedish medicolegal autopsy cases autopsied between 2010 and 2019. The model was validated in 296 nonobese young adult suicidal hanging cases.For a decedent of average height (174 cm), the evidence that a heart weight was enlarged reached weak support at approximately 430 g, substantial support at approximately 480 g, and strong support at 520 g. The modeled prevalence of cardiac enlargement was very high among elderly and obese decedents.We believe that our model is more applicable in a medicolegal setting than those previously published. The presented quantification of the degree of uncertainty regarding diagnosis can help the pathologist in diagnosing cardiac enlargement. To facilitate the use of this model, we also made it available through a simple online tool ( https://formedum.shinyapps.io/HeartWeightCalc/ ).

Significant difference in cardiac ventricular dimensions when measured using two different standard methods

Cardiac ventricular dimensions measured at postmortem examination are used to assess whether there is hypertrophy of the heart chambers. However, there is no clear consensus on where these measurements should be taken. Some have proposed this should be measured at the mid-ventricular level, but others advocate it should be measured at a set distance (e.g. 20 mm) from the base of the heart. Twenty consecutive adult hearts were examined and showed the ventricular dimensions were significantly higher (mean: 5-15 mm, p < 0.01) when measured at a level 20 mm from the base of the heart compared to the mid-ventricular level. Of clinical significance is that in slightly less than half the cases, normal ventricular dimensions at mid ventricle level fell within the criteria considered pathological (> 40 mm) when measured at 20 mm from the base of the heart. In terms of actual ventricular dimensions, only the left ventricle diameter measured at 20 mm from the base of the heart correlated significantly (albeit moderately) with heart weight, suggesting it can be a predictor for cardiac hypertrophy.

Obesity Cardiomyopathy in Sudden Cardiac Death: A Distinct Entity? A Comparative Study

Background

Obesity cardiomyopathy (OCM) can be associated with sudden cardiac death (SCD) but its pathologic features are not well described.

Objectives

The objective of this study was to characterize the clinical and pathological features of OCM associated with SCD.

Methods

This was a retrospective case control autopsy study. OCM was identified by an increased heart weight (>550 g in males; >450 g in females) in individuals with obesity (body mass index [BMI] ≥30 kg/m2) in the absence of other causes. Cases of OCM with SCD were compared to sex and age matched SCD controls with obesity or with normal weight (BMI 18.5-24.9 kg/m2) and morphologically normal hearts. Autopsy measures included: heart weight, atrial dimensions, ventricular wall thickness, and epicardial adipose tissue. Fibrosis was assessed microscopically.

Results

Of 6,457 SCD cases, 53 cases of OCM were identified and matched to 106 controls with obesity and 106 normal weight controls. The OCM mean age at death of individuals with OCM was 42 ± 12 with a male predominance (n = 34, 64%). Males died younger than females (40 ± 13 vs 45 ± 10, P = 0.036). BMI was increased in OCM cases compared to controls with obesity (42 ± 8 vs 35 ± 5). The average heart weight was 598 ± 93 g in OCM. There were increases in right and left ventricular wall thickness (all P < 0.05) in OCM cases compared to controls. Right ventricular epicardial fat was increased in OCM compared to normal weight controls only. Left ventricular fibrosis was identified in 7 (13%) cases.

Conclusions

OCM may be a specific pathological entity associated with SCD. It is most commonly seen in young males with increased BMI.

Effect of sex, age and body measurements on heart weight, atrial, ventricular, valvular and sub-epicardial fat measurements of the normal heart

AIMS

Descriptive morphological studies of the normal heart are lacking. Previous autopsy studies have focused mainly on heart weight. We characterize the normal heart by providing normal dimensions of the atria, ventricles, valves and sub-epicardial fat, comparing the findings in terms of sex, age and body measurements.

METHODS

From 3602 referrals to our cardiovascular pathology unit, pathological criteria used for the classification of a morphologically normal heart were a weight of below 500 grams in males, and below 400 grams in females. Diseased hearts were excluded on anatomical and histological evaluation.

RESULTS

We diagnosed 1062 morphologically normal hearts. Mean age at death was 34±12, with a male predominance (701, 66%). Age was similar in females and males (35±13 vs 34±12). Females had a significantly lower heart weight (285±55 vs 374±64). Sex was an independent predictor of most measurements. The atrial and ventricular cavities were significantly larger in males. All ventricular measurements of muscle thickness were larger in males. All valvular circumferences were larger in males. In contrast, sub-epicardial fat was significantly thicker in females in 6 of 7 regions. This is the first study to provide a calculator to give expected values according to sex, age, height and weight.

CONCLUSIONS

Major differences between the sexes exist in the morphologically normal heart. These variations should be considered when assessing cardiac structure in imaging for risk stratification and diagnosis in the cardiomyopathies, as well as in treatment outcomes.

Sudden cardiac death in the young: A consensus statement on recommended practices for cardiac examination by pathologists from the Society for Cardiovascular Pathology

Sudden cardiac death is, by definition, an unexpected, untimely death caused by a cardiac condition in a person with known or unknown heart disease. This major international public health problem accounts for approximately 15-20% of all deaths. Typically more common in older adults with acquired heart disease, SCD also can occur in the young where the cause is more likely to be a genetically transmitted process. As these inherited disease processes can affect multiple family members, it is critical that these deaths are appropriately and thoroughly investigated. Across the United States, SCD cases in those less than 40 years of age will often fall under medical examiner/coroner jurisdiction resulting in scene investigation, review of available medical records and a complete autopsy including toxicological and histological studies. To date, there have not been consistent or uniform guidelines for cardiac examination in these cases. In addition, many medical examiner/coroner offices are understaffed and/or underfunded, both of which may hamper specialized examinations or studies (e.g., molecular testing). Use of such guidelines by pathologists in cases of SCD in decedents aged 1-39 years of age could result in life-saving medical intervention for other family members. These recommendations also may provide support for underfunded offices to argue for the significance of this specialized testing. As cardiac examinations in the setting of SCD in the young fall under ME/C jurisdiction, this consensus paper has been developed with members of the Society of Cardiovascular Pathology working with cardiovascular pathology-trained, practicing forensic pathologists.

Concealed Cardiomyopathy in Autopsy-Inconclusive Cases of Sudden Cardiac Death and Implications for Families

BACKGROUND

Genetic testing following sudden cardiac death (SCD) is currently guided by autopsy findings, despite the inherent challenges of autopsy examination and mounting evidence that malignant arrhythmia may occur before structural changes in inherited cardiomyopathy, so-called "concealed cardiomyopathy" (CCM).

OBJECTIVES

The authors sought to identify the spectrum of genes implicated in autopsy-inconclusive SCD and describe the impact of identifying CCM on the ongoing care of SCD families.

METHODS

Using a standardized framework for adjudication, autopsy-inconclusive SCD cases were identified as having a structurally normal heart or subdiagnostic findings of uncertain significance on autopsy. Genetic variants were classified for pathogenicity using the American College of Medical Genetics and Genomics guidelines. Family follow-up was performed where possible.

RESULTS

Twenty disease-causing variants were identified among 91 autopsy-inconclusive SCD cases (mean age 25.4 ± 10.7 years) with a similar rate regardless of the presence or absence of subdiagnostic findings (25.5% vs 18.2%; P = 0.398). Cardiomyopathy-associated genes harbored 70% of clinically actionable variants and were overrepresented in cases with subdiagnostic structural changes at autopsy (79% vs 21%; P = 0.038). Six of the 20 disease-causing variants identified were in genes implicated in arrhythmogenic cardiomyopathy. Nearly two-thirds of genotype-positive relatives had an observable phenotype either at initial assessment or subsequent follow-up, and 27 genotype-negative first-degree relatives were released from ongoing screening.

CONCLUSIONS

Phenotype-directed genetic testing following SCD risks under recognition of CCM. Comprehensive evaluation of the decedent should include assessment of genes implicated in cardiomyopathy in addition to primary arrhythmias to improve diagnosis of CCM and optimize care for families.

Use of potassium ion channel and spliceosome proteins as diagnostic biomarkers for sudden unexplained death in schizophrenia

Sudden unexplained death in schizophrenia (SUD-SCZ) is not uncommon and its incidence is approximately three times higher than that in the general population. However, diagnosis of SUD-SCZ remains a great challenge in forensic pathology. This study designed a two-phase study to investigate whether three proteins, namely two potassium ion channel proteins (KCNJ3 and KCNAB1) and one spliceosome protein (SF3B3) that were identified in our previous work, could be applied in the postmortem diagnosis of SUD-SCZ. Immunohistochemical staining of the three biomarkers, followed by a rigorous quantitative analysis, was performed on heart specimens from both SUD-SCZ and control groups. A diagnostic software based on the logistic regression formula derived from the test phase data was then constructed. In the test phase, we found that the staining intensities of KCNJ3, KCNAB1, and SF3B3 were all significantly lower in the SUD-SCZ group (n = 20) as compared with the control group that died from non-natural causes (n = 25), with fold-changes being 14.85 (p < 0.001), 4.13 (p = 0.028) and 2.12 (p = 0.048), respectively. Receiver operating characteristic analysis further illustrated that combination of the three biomarkers achieved the optimal diagnostic specificity (92%) and area under the curve (0.886). In the validation phase, the diagnostic software was confirmed to be a promising tool for predicting the risk of SUD-SCZ in authentic cases. Our study provided a valid strategy towards the practical diagnosis of SUD-SCZ by using KCNJ3, KCNAB1, and SF3B3 proteins as diagnostic biomarkers.

Organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder: a nation-wide 2-year cross-sectional study

AIMS

To document organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder and estimate the extent to which individual characteristics are associated with pulmonary, cardiovascular, hepatic or renal pathologies.

DESIGN

Two-year cross-sectional nation-wide study.

SETTING

Norway.

PARTICIPANTS

Among all 200 patients who died during opioid agonist treatment between 1 January 2014 and 31 December 2015, 125 patients (63%) were autopsied. Among these, 122 patients (75% men) had available autopsy reports and were included. The mean age at the time of death was 48 years.

MEASUREMENTS

Information on pulmonary, cardiovascular, hepatic and renal pathologies were retrieved from forensic or medical autopsy reports, with no (0) and yes (1) as outcome variables and age, sex and body mass index as covariates in logistic regression analyses.

FINDINGS

Pathologies in several organs were common. Two-thirds (65%) of the decedents had more than two organ system diseases. The most common organ pathologies were chronic liver disease (84%), cardiovascular disease (68%) and pulmonary emphysema (41%). In bivariate analyses, only older age was associated with any pulmonary pathology [odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.01-1.10], cardiovascular pathology (OR = 1.11; 95% CI = 1.05-1.17) and renal pathology (OR = 1.05; 95% CI = 1.00-1.11). Older age remained independently associated with cardiovascular pathology (OR = 1.10; 95% CI = 1.04-1.16) and renal pathology (OR = 1.06; 95% CI = 1.01-1.12) adjusted for body mass index and sex.

CONCLUSIONS

Among autopsied Norwegians who died during opioid agonist treatment in 2014 and 2015, two-thirds had more than two organ system diseases, despite their mean age of 48 years at the time of death. Older age was independently associated with at least one cardiovascular or renal pathology after adjusting for sex and body mass index.

Heart Weight Is an Independent Factor Associated With, But Is a Poor Predictor for, Sudden Cardiac Death

ABSTRACT

An enlarged heart can cause electrical instability and impaired contractility, leading to fatal arrhythmia and acute heart failure, and is associated with sudden cardiac death. However, there is limited postmortem evidence on whether heart weight is an independent factor associated with sudden cardiac death. This 18-month retrospective study examined 108 adult heart weights in which all the hearts were weighed after dissection, blood and blood clots removed, rinsed in water, and pat dried. The multivariate logistic regression analysis showed heart weight was an independent factor associated with sudden cardiac death. However, after normalization, the heart weight was a poor predictor of sudden cardiac death with an area under the curve less than 0.7 in the plotted receiver operating characteristic curve.

Estimating heart mass from heart volume as measured from post-mortem computed tomography

Heart mass can be predicted from heart volume as measured from post-mortem computed tomography (PMCT), but with limited accuracy. Although related to heart mass, age, sex, and body dimensions have not been included in previous studies using heart volume to estimate heart mass. This study aimed to determine whether heart mass estimation can be improved when age, sex, and body dimensions are used as well as heart volume. Eighty-seven (24 female) adult post-mortem cases were investigated. Univariable predictors of heart mass were determined by Spearman correlation and simple linear regression. Stepwise linear regression was used to generate heart mass prediction equations. Heart mass estimate performance was tested using median mass comparison, linear regression, and Bland-Altman plots. Median heart mass (P = 0.0008) and heart volume (P = 0.008) were significantly greater in male relative to female cases. Alongside female sex and body surface area (BSA), heart mass was univariably associated with heart volume in all cases (R² = 0.72) and in male (R² = 0.70) and female cases (R² = 0.64) when segregated. In multivariable regression, heart mass was independently associated with age and BSA (R² adjusted = 0.46-0.54). Addition of heart volume improved multivariable heart mass prediction in the total cohort (R² adjusted = 0.78), and in male (R² adjusted = 0.74) and female (R² adjusted = 0.74) cases. Heart mass estimated from multivariable models incorporating heart volume, age, sex, and BSA was more predictive of actual heart mass (R² = 0.75-0.79) than models incorporating either age, sex, and BSA only (R² = 0.48-0.57) or heart volume only (R² = 0.64-0.73). Heart mass can be more accurately predicted from heart volume measured from PMCT when combined with the classical predictors, age, sex, and BSA.

Revisited Upper Reference Limits for Highly Sensitive Cardiac Troponin T in Relation to Age, Sex, and Renal Function

(1) Background: Highly sensitive cardiac troponin T (hs-cTnT) plays an essential role in the diagnosis of myocardial injury. The upper reference limit of the respective assay is generally applied, irrespective of age, renal function, or sex. We aimed to identify age-adjusted and sex-adjusted upper reference limits in relation to renal function in a large population-based cohort without cardiac diseases. (2) Methods: We included 5428 subjects of the population-based LIFE-Adult cohort, free of diagnosed cardiac diseases. Sex-adjusted and age-adjusted 99th percentiles for hs-cTnT in subjects with preserved renal function were obtained. (3) Results: The hs-cTnT values were higher in men of all age groups. In both sexes, an increasing age positively correlated with higher hs-cTnT values. Hs-cTnT weakly correlated with serum creatinine. The three-dimensional analysis of age, creatinine, and hs-cTnT showed no relevant additional effect of creatinine on hs-cTnT. In men aged above 60 and women above 70, the calculated 99th percentiles clearly exceeded the commonly applied thresholds. (4) Conclusion: Age and sex have a major impact on the serum concentration of hs-cTnT, while renal function does not. We propose to consider age-adjusted and sex-adjusted reference values.

The effects of drying the rinsed dissected heart on postmortem heart weight

Blood and blood clots should be removed from the heart chambers before being weighed. The actual method in removing blood and blood clots may vary and can include manual removal with subsequent rinsing the heart in water. It is unclear whether drying the rinsed heart affects the heart weight. The objective of this article was to investigate the effects drying the rinsed dissected heart (residual rinsing water) on postmortem heart weight. The prospective study compared 44 dissected heart weights after being rinsed and after being pat dried. An average 18-20 g of residual rinsing water (4% of heart weight) was present in the dissected heart. The amount of residual rinsing water correlates positively with heart weight. The effects of drying the rinsed dissected heart were considered clinically insignificant. Although being clinically insignificant, this study highlights the lack of standardized approach in weighing the heart and the potential implications in interpreting heart weights.

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.

Cutoff value for hypertrophic heart weight in the Japanese population

BACKGROUND

Cardiac hypertrophy is a clinical risk factor for cardiovascular death (CVD) frequently recorded in autopsy reports, but the diagnostic criteria for the condition have not been clearly-established for autopsy. This study aimed to estimate the cutoff value for hypertrophic heart weight that can efficiently assist the postmortem diagnosis of CVD.

METHODS

We analyzed accumulated autopsy data from 3534 individuals aged 0-101 years.

RESULTS

We found that heart weight increased linearly with a person's age until 20 years, after which it remained stable. The mean heart weight in CVD cases was 473 g in men and 379 g in women. The mean heart weight in non-CVD cases was 385 g in men and 320 g in women. Receiver operating characteristic curve analysis for CVD assessment revealed that the cutoff value of heart weight was 407 g (odds ratio of 4.2) in men and 327 g (2.6) in women, and that of heart weight/body height was 2.38 g/cm (4.0) in men and 2.15 g/cm (2.6) in women, respectively. Overall, heart weight was a more useful predictor of CVD in men than in women. In logistic regression analysis, the predictive power of heart weight for CVD was higher than that of body mass index in both sexes.

CONCLUSION

Thus, the criteria for hypertrophic heart weight are practical and useful for autopsy recordings, and it can be helpful for postmortem diagnosis of CVD. Our report is the first to reveal the cutoff value for hypertrophic heart weight in the Japanese population.

Prevalence of Abnormal Heart Weight After Sudden Death in People Younger than 40 Years of Age

Background After sudden cardiac death in people aged <40 years, heart weight is a surrogate for cardiomegaly and a marker for cardiomyopathy. However, thresholds for cardiomegaly based on heart weight have not been validated in a cohort of cases of sudden cardiac death in young people. Methods and Results We surveyed medical examiner offices to determine which tools were used to assess heart weight norms. The survey determined that there was no gold standard for cardiomegaly (52 centers reported 22 different methods). We used a collection of heart weight data from sudden deaths in the Northwestern Sudden Death Collaboration (NSDC) to test the 22 methods. We found that the methods reported in our survey had little consistency: they classified between 18% and 81% of NSDC hearts with cardiomegaly. Therefore, we obtained biometric and postmortem data from a reference population of 3398 decedents aged <40 years. The reference population was ethnically diverse and had no known cardiac pathology on autopsy or histology. We derived and validated a multivariable regression model to predict normal heart weights and a threshold for cardiomegaly (upper 95% CI limit) in the young reference population (the Chicago model). Using the new model, the prevalence of cardiomegaly in hearts from the NSDC was 19%. Conclusions Medical examiner offices use a variety of tools to classify cardiomegaly. These approaches produce inconsistent results, and many overinterpret cardiomegaly. We recommend the model proposed to classify postmortem cardiomegaly in cases of sudden cardiac death in young people.

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.

Characteristic Histopathological Findings and Cardiac Arrest Rhythm in Isolated Mitral Valve Prolapse and Sudden Cardiac Death

Background

The association between mitral valve prolapse (MVP) and sudden death remains controversial. We aimed to describe histopathological changes in individuals with autopsy‐determined isolated MVP (iMVP) and sudden death and document cardiac arrest rhythm.

Methods and Results

The Australian National Coronial Information System database was used to identify cases of iMVP between 2000 and 2018. Histopathological changes in iMVP and sudden death were compared with 2 control cohorts matched for age, sex, height, and weight (1 group with noncardiac death and 1 group with cardiac death). Data linkage with ambulance services provided cardiac arrest rhythm for iMVP cases. From 77 221 cardiovascular deaths in the National Coronial Information System database, there were 376 cases with MVP. Individual case review yielded 71 cases of iMVP. Mean age was 49±18 years, and 51% were women. Individuals with iMVP had higher cardiac mass (447 g versus 355 g; P<0.001) compared with noncardiac death, but similar cardiac mass (447 g versus 438 g; P=0.64) compared with cardiac death. Individuals with iMVP had larger mitral valve annulus compared with noncardiac death (121 versus 108 mm; P<0.001) and cardiac death (121 versus 110 mm; P=0.002), and more left ventricular fibrosis (79% versus 38%; P<0.001) compared with noncardiac death controls. In those with iMVP and witnessed cardiac arrest, 94% had ventricular fibrillation.

Conclusions

Individuals with iMVP and sudden death have increased cardiac mass, mitral annulus size, and left ventricular fibrosis compared with a matched cohort, with cardiac arrest caused by ventricular fibrillation. The histopathological changes in iMVP may provide the substrate necessary for development of malignant ventricular arrhythmias.

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.

Assessment of a simple method of heart weight estimation by postmortem computed tomography

BACKGROUND

Measurement of heart weight is important when investigating cause of death, but there is presently no satisfactory method of heart weight estimation by postmortem computed tomography (PMCT).

METHOD

We investigated 33 consecutive cases that underwent both PMCT and autopsy between February 2008 and June 2014. Heart and left ventricular (LV) weights were calculated by PMCT morphometry. We used a simple method to estimate LV weight: We assumed that LV was an ellipsoid and multiplied its volume on PMCT with myocardial specific gravity. We then compared the various heart and LV weights using linear regression. The calculated and estimated LV weights on PMCT were also compared.

RESULTS

It was not possible to predict heart weight at autopsy from PMCT (R² = 0.53). However, heart weight at autopsy could be accurately predicted from LV weight calculated by PMCT (R² = 0.77). In addition, there was a strong correlation between the estimated and calculated LV weights by PMCT (R² = 0.92). Heart weight at autopsy could also be accurately predicted using the PMCT-estimated LV weight (R² = 0.72).

CONCLUSION

Heart weight at autopsy could be accurately predicted using a simple method in which LV volume was assumed to be an ellipsoid on PMCT.

Higher Heart Weight in New Zealand Māori and Pacific Islanders

Heart weight is dependent on sex, age, height, and weight. Although previous autopsy studies showed no differences in heart weight between different ethnic groups, none have examined the New Zealand population of Māori and Pacific Islanders (Polynesians). The presented study compared heart weights between 101 European and 85 Polynesian suicide hanging deaths from New Zealand. Univariate linear regression coefficients for age, male sex, height, body weight, body mass index, and Polynesian ethnicity were positive and significant (P < 0.05). Apart from body mass index, subsequent multivariate analysis showed that all regression coefficients remained positive and significant (P < 0.05). Polynesian ethnicity seemed to be an independent predictor for increased heart weight in the study population. Apart from possible genetic factors, the higher heart weight in Polynesians may have other underlying reasons. Caution is required when interpreting heart weight in cases of sudden natural deaths, especially in this population.

Love Death-A Retrospective and Prospective Follow-Up Mortality Study Over 45 Years

BACKGROUND

Although sexual activity can cause moderate stress, it can cause natural death in individuals with pre-existing illness. The aim of this study was to identify additional pre-existing health problems, sexual practices, and potential circumstances that may trigger fatal events.

METHODS

This medicolegal postmortem, retrospective, and prospective study is based on data of autopsies performed at the Institute of Legal Medicine of the University hospital, Goethe-University, Frankfurt/Main, Germany.

OUTCOMES

Identification of pre-existing health problems, sexual practices, and potential circumstances than could trigger fatal events.

RESULTS

From 1972 to 2016 (45 years) approximately 38,000 medicolegal autopsies were performed, of which 99 cases of natural death were connected to sexual activities (0.26%). Except for eight women, men represented most cases. The women's mean age was 45 years (median = 45) and the men's mean age was 57.2 years (median = 57). Causes of death were coronary heart disease (n = 28), myocardial infarction (n = 21) and reinfarction (n = 17), cerebral hemorrhage (n = 12), rupture of aortic aneurysms (n = 8), cardiomyopathy (n = 8), acute heart failure (n = 2), sudden cardiac arrest (n = 1), myocarditis (n = 1), and a combination of post myocardial infarction and cocaine intoxication (n = 1). Most cases showed increased heart weights and body mass indices. Death occurred mainly during the summer and spring and in the home of the deceased. If sexual partners were identified, 34 men died during or after sexual contact with a female prostitute, two cases at least two female prostitutes. Nine men died during or after sexual intercourse with their wife, in seven cases the sexual partner was a mistress, and in four cases the life partner. Five men died during homosexual contacts. Based on the situation 30 men were found in, death occurred during masturbation. Of the women, five died during intercourse with the life partner, two died during intercourse with a lover or friend, and in one case no information was provided.

CLINICAL TRANSLATION

Natural deaths connected with sexual activity appear to be associated with male sex and pre-existing cardiovascular disorders. Most cases recorded occurred with mistresses, prostitutes, or during masturbation. If death occurs, the spouse or life partner might need psychological support.

STRENGTH AND LIMITATIONS

To our knowledge, the present study contains the largest collection of postmortem data on natural deaths connected with sexual activities. However, the cases presented were of forensic interest; a larger number of undetected cases especially in the marital or stable relationship sector must be assumed.

CONCLUSION

Patients should be informed about the circumstances that could trigger the "love death." Lange L, Zedler B, Verhoff MA, Parzeller M. Love Death-A Retrospective and Prospective Follow-Up Mortality Study Over 45 Years. J Sex Med 2017;14:1226-1231.

Morphometric data on severely and morbidly obese deceased, established on forensic and non-forensic autopsies

With the widespread increase in the incidence of obesity, autopsies on severely and morbidly obese deceased have become common in the USA. Standard reference tables for organ weights provide little or no information on individuals with a body mass index greater than 35 kg/m(2). Although several recent reports have provided organ weights for small numbers of morbidly obese persons who died naturally from a variety of causes, these data may have been affected by comorbidities. Furthermore, they did not provide information relative to differences in organ weight based on gender, age, and race. The aim of the present study was to fill this void by developing reference tables for organ weights of severely and morbidly obese individuals. Our study was based on data from 802 forensic and medical autopsies, including 435 cases of death of natural and 367 of non-natural causes. Organ weights were compared between these groups, and reference ranges were generated. Significant variability was found in organ weights especially among deceased older than 40 years who died naturally, suggesting that comorbidities affect organ weight. Reference tables were compiled for organ weights and morphometric data based on gender, age, and race. Since obesity is a pathological condition affecting organ weight, these reference tables do not reflect normal organ weights but only weight as seen in severely and morbidly obese individuals. They should be useful to pathologists who perform forensic and non-forensic autopsies.