Intramural coronary artery dysplasia of the ventricular septum and sudden death

Fibromuscular dysplasia of the coronary arteries: An unusual case of sudden death and review of the literature

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.

Pathological Appearance of a Case of Preclinical Multiple System Atrophy: A Comparison With Advanced Cases

We aimed to investigate the frequency of multiple system atrophy (MSA) in a large number of forensic autopsies and characterize the pathological appearance of preclinical MSA. We investigated a series of 1930 brains from forensic autopsies. In addition to performing immunohistochemistry for phosphorylated α-synuclein, the levels of 3 autonomic nervous system markers (catecholaminergic, serotonergic, and cholinergic) were used to assess the peripheral nerve (heart and superior cervical ganglion) and medulla oblongata. The results were compared to those of healthy control and Parkinson disease (PD) cases. Four cases (0.21%) were identified as having MSA. Cases 1-3 were symptomatic, and Case 4 was incipient; that is, although no neuronal loss was evident, the cerebellar dentate nucleus exhibited marked grumose degeneration. Immunohistochemistry revealed a marked reduction in autonomic nervous system marker levels expressed in the medulla; this reduction was more prominent in the 3 symptomatic MSA cases than in the PD case. The opposite occurred for the peripheral nerve. Case 4 exhibited mild cholinergic nerve reduction. Two cases showed possible significant pathological changes in the heart. Grumose degeneration, few oligodendroglial cytoplasmic inclusions without neuronal loss, and less reduction of autonomic nervous tissue were more prominent in the preclinical case than in symptomatic cases.

First international consensus on the diagnosis and management of fibromuscular dysplasia

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.

First International Consensus on the diagnosis and management of fibromuscular dysplasia

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.

Sudden Death Due to Cystic Tumor of the Atrioventricular Node and Fibromuscular Dysplasia Involving Branches of the Coronary Arteries

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.

Cardiac pathology findings in 252 cats presented for necropsy; a comparison of cats with unexpected death versus other deaths

OBJECTIVES

To report necropsy and myocardial histopathology in cats with unexpected death and expected death/euthanasia, comparing findings in 4 groups of cats: unexpected death with noncardiac disease (UD-NC); unexpected death with cardiac disease (UD-C); expected death/euthanasia due to noncardiac disease with incidental cardiac disease (OD + HD); and expected death/euthanasia due to congestive heart failure (CHF).

ANIMALS

Two hundred fifty-two cats undergoing necropsy at a single centre.

METHODS

Signalment, history, body weight, heart weight and myocardial thickness were obtained from medical records. Cardiac histopathology slides were reviewed blindly by a single observer. Data were analysed using a Chi squared, Fisher's exact, Kruskal-Wallis tests or ANOVA as appropriate.

RESULTS

Death at a veterinary clinic and suspected poisoning were the most common reasons for necropsy in 158 cats with an unexpected death. No cause other than cardiac disease was found in 87/158 (55.1%), with hypertrophic cardiomyopathy identified in 68/87 (78%) of UD-C cats. Expected deaths or euthanasia occurred in 27 cats with CHF and 67 cats with concurrent heart disease (OD + HD). Myofiber disarray, interstitial fibrosis, subendocardial fibrosis and intramural arteriolosclerosis were more prevalent in UD-C cats than in UD-NC cats, and subendocardial fibrosis and arteriolosclerosis were more prevalent in UD-C cats than in CHF and OD + HD cats.

CONCLUSIONS

Cardiac disease, and hypertrophic cardiomyopathy in particular, was commonly present in cats that died unexpectedly in this study population. Subendocardial fibrosis and intramural arteriolosclerosis were more common in cats with unexpected death with cardiac disease than in other cats.

Age-related fibromuscular dysplasia in the human left ventricle papillary muscles arteries

We describe histologically cases of patients between 31 and 60 years of age who had fibromuscular dysplasia (FMD) in the tunica media (TM) of the left ventricle papillary muscles (PM) arteries. We also compared them with our previous findings in subjects younger than 30 years of age. We examined histologically samples taken from the tip of the anterior PM of the left ventricle in 200 healthy male hearts. In 33 cases (16.5 %), FMD was in the TM. We divided these cases into three subgroups (A, B, C) based on the degree of replacement of smooth muscle cells by fibrous tissue, and thus identified 17, 11 and 5 cases, respectively. Until the age of 41, the typical lesions were often localized within the TM. Beyond that age, the fibrous tissue increased in the TM wall and in the surrounding area of the vessels, causing dysfunction of the PM. Degenerative lesions, as well as inflammatory infiltration, were found after the age of 53. The findings of this study will be useful to cardiologists and cardiac surgeons, in pointing out that, after the age of 44 years old, some PM and their supporting valves may present a degree of dysfunction.

Use of contrast echocardiography for quantitative and qualitative evaluation of myocardial perfusion and pulmonary transit time in healthy dogs

OBJECTIVE

To evaluate reproducibility of ejection fraction (EF), myocardial perfusion (MP), and pulmonary transit time (PTT) measured in a group of dogs by use of contrast echocardiography and to examine safety of this method by evaluating cardiac troponin I concentrations.

ANIMALS

6 healthy dogs.

PROCEDURES

2 bolus injections and a constant rate infusion of contrast agent were administered IV. Echocardiographic EF was determined by use of the area-length method and was calculated without and with contrast agent. The PTT and normalized PTT (PTT/mean R-R interval) were measured for each bolus. Constant rate infusion was used for global MP evaluation, and regional MP was calculated by use of a real-time method in 4 regions of interest of the left ventricle. Cardiac troponin I concentration was analyzed before and after contrast agent administration. Intraoberserver and interobserver variability was calculated.

RESULTS

EF was easier to determine with the ultrasonographic contrast agent. For the first and second bolus, mean ± SD PTT was 1.8 ± 0.2 seconds and 2.1 ± 0.3 seconds and normalized PTT was 3.4 ± 0.3 seconds and 3.5 ± 0.3 seconds, respectively. A coefficient of variation < 15% was obtained for global MP but not for the regional MPs. No differences were detected between precontrast and postcontrast cardiac troponin I concentrations.

CONCLUSIONS AND CLINICAL RELEVANCE

Contrast echocardiography appeared to be a repeat-able and safe technique for use in the evaluation of global MP and PTT in healthy dogs, and it improved delineation of the endocardial border in dogs.

What is Sudden Cardiac Death?

Sudden cardiac death (SCD) is a rapid, unexpected death due to cardiac causes. The differential diagnosis includes diseases from all four structural divisions of the heart: the blood vessels, myocardium, valves, and conduction system. Although ischemic heart disease is a common cause of SCD, acute myocardial infarcts and/or coronary thromboses are not always detected and are not required to make the diagnosis of death due to atherosclerotic coronary disease. Some people die suddenly from heart disease with a grossly and microscopically normal heart. Molecular analysis of some of these autopsy-negative, sudden unexplained deaths (SUD) may detect putative cardiac channel mutations.

There are three SCD scenarios that are of particular interest to forensic pathologists: sudden cardiac deaths in young athletes, during criminal altercations (homicide by heart attack), and in other hostile environments. In young athletes, most sudden deaths involve cardiac disease and include cardiomyopathies, congenital coronary artery anomalies, myocarditis, and channelopathies. One must, however, consider other causes in these deaths (e.g., commotio cordis, hyperthermia, sickle cell trait). Homicide-by-heart-attack deaths are those in which the cause of death is an acute exacerbation of underlying cardiac disease, however, the manner is homicide because a criminal act triggered the lethal pathologic cascade. A sudden cardiac arrest may occur in hostile locations with resultant trauma (e.g., while driving a motor vehicle). When the event occurs in the bathtub or other body of water, the question of whether the person died naturally from heart disease or unnaturally from trauma (e.g., drowning) often arises. One should not be mislead by the initial physical surroundings of the death (i.e., in a motor vehicle collision, or swimming pool) and fail to distinguish a natural sudden death from an accidental one.

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

Ruptured cerebral aneurysm and acute coronary artery dissection in the setting of multivascular fibromuscular dysplasia: a case report

Fibromuscular dysplasia (FMD) is a segmental noninflammatory nonatherosclerotic vascular disease that has been described in almost every arterial bed, including the cerebral and coronary arteries. FMD of cerebral vessels has been associated with development of saccular aneurysms in the involved vessels. Acute dissection of coronary arteries is also a rare complication of FMD. Herein, we report the first case of both complications of FMD occurring in a single patient-a ruptured anterior communicating artery aneurysm and a right coronary artery dissection occurring in a 38-year-old woman. At autopsy, FMD was found in multiple vascular beds. Our findings reveal the potential for involvement of several vascular beds in patients with FMD, resulting in multiple vascular complications.

Arteriosclerotic changes in the myocardium, lung, and kidney in dogs with chronic congestive heart failure and myxomatous mitral valve disease

BACKGROUND

The occurrence of small vessel arteriosclerosis in the myocardium, kidney, and lung in dogs with naturally occurring myxomatous mitral valve disease has not been previously investigated systematically.

METHODS

Twenty-one dogs with naturally occurring congestive heart failure and 21 age-matched, sex-matched, and weight-matched control dogs underwent extensive pathological and histopathological examination. Morphometry and scoring of tissue sections were used to measure arterial narrowing and fibrosis in the myocardium, kidney, and lung; and intimal thickness and plaque formation in the aorta and pulmonary artery.

RESULTS

Dogs with congestive heart failure had significantly more arterial narrowing in the left ventricle (P < .003), lung (P < .0001), and kidney (P < .02); intimal-medial thickening in the pulmonary artery (P = .04); and fibrosis in the left ventricle (P < .0001) than control dogs. However, they did not have more plaque formation or intimal-medial thickening in the aorta than controls. There was significantly more arterial narrowing in papillary muscles than in all other locations in dogs with congestive heart failure (P < .002). In control dogs, arterial changes were less pronounced and did not differ in different locations.

CONCLUSIONS

Dogs with naturally occurring myxomatous mitral valve disease have significantly more arterial changes in the myocardium, lung, and kidney, and significantly more fibrosis in the myocardium than control dogs. This could have important implications in the management of myxomatous mitral valve disease and raises interesting questions about the occurrence and importance of intramural small vessel disease in humans with primary mitral valve prolapse.

Global remodeling of the ventricular interstitium in idiopathic myocardial fibrosis and sudden cardiac death

OBJECTIVE

Characterization of a distinct, and as yet unexplained phenotype of sudden cardiac death (SCD).

BACKGROUND

In a subgroup of patients with SCD, postmortem findings are limited to isolated idiopathic myocardial fibrosis (IMF). The absence of confounding factors may facilitate evaluation of the relationship between myocardial fibrosis and ventricular arrhythmogenesis.

METHODS

Six patients with IMF were identified from a postmortem, consecutive 13-year series of 270 subjects presenting with SCD. Ventricular interstitial remodeling was assessed quantitatively and qualitatively and comparisons made with 6 age- and sex-matched control subjects who suffered noncardiac death. Myocardial collagen volume fraction and perivascular fibrosis ratio were determined and evidence for inflammatory response and apoptotic cell death was sought. The potential role of transforming growth factor beta 1 (TGF-beta(1)) in the pathogenesis of IMF was evaluated.

RESULTS

Overall myocardial collagen volume fraction was 1.6-fold higher in IMF (mean age 34 +/- 4 yrs) vs. controls (mean age 34 +/- 4 yrs, .022 +/- .001 vs .013 +/- .001; P < .001). Collagen volume fraction increase was diffuse but disproportionately so in the LV inferior wall (3.4-fold increase; .035 +/- .005 vs .012 +/- .018; P < .001). Perivascular fibrosis ratio was also increased (.770 +/- .014 vs .723 +/- .010; P = .007). There was no evidence of either myocardial inflammatory response or myocyte apoptosis in cases or controls. Expression of TGF-beta(1) was significantly increased in IMF vs controls.

CONCLUSION

IMF involves diffuse and heterogeneous remodeling of the ventricular interstitium, with a predilection for the LV inferior wall. TGF-beta(1) is a potential mediator of interstitial remodeling in IMF and SCD.

Sudden unexpected death of a 17-year-old male infected with the influenza virus

We report a case of sudden unexpected death in a 17-year-old male student showing similar clinical background and pathological findings to Reye's syndrome. He was found following cardio-pulmonary arrest in his bed, and was immediately transferred to a hospital. However, resuscitation was not successful. He had a history of high fever of 38.3 degrees C, general malaise, myalgia, and gastrointestinal discomfort for the 2 days prior to his death, and an injection of pylazolon and medication comprising anti-emetics had been administered the day before he died. His biochemical findings showed almost normal levels of transaminase, electrolytes and protein fractions at the emergency room, but blood from the heart at autopsy revealed a high titer of the influenza A virus. Macroscopically, in addition to considerable fatty metamorphosis of the liver, concentric hypertrophy of the left ventricle, muscular bridge of left anterior descending artery, moderate coronary atherosclerosis, and mild downward displacement of the septal leaflet of the tricuspid valve were noted in the heart. Although panlobular microvesicular fatty infiltration of the liver was seen, deposition of lipid droplets was detected only in hepatocytes by frozen section of several organs. Serial sectioning of the epicardial coronary arteries showed about 50% stenosis at the distal site of the left circumflex artery, and diffuse interstitial fibrosis was evident in the bilateral ventricle and this was relatively severe for his age. In addition, the atrioventricular (AV) node artery showed severe narrowing just before entering the AV node, and downward displacement of the AV node with longitudinal elongation was also remarkable. We consider that the cause of death was sudden cardiac death rather than Reye's syndrome (RS), and that an arrhythmogenic event due to some preceding unusual cardiac lesions may have become overt due to the influenza infection and/or some related disorders. The present case would seem to suggest that a postmortem diagnosis of RS should be determined very carefully in cases of sudden death, even if the general circumstances would seem to be consistent with RS.

Multiple spontaneous coronary artery dissections in association with anomalous origin of right coronary and intramural coronary artery dysplasia

We present a case of sudden death due to spontaneous acute coronary artery dissection. In addition, there was a healing spontaneous coronary dissection, intramural coronary artery dysplasia, and an anomalous origin of the right coronary artery from the pulmonary trunk. The coincidence of multiple spontaneous coronary dissections, coronary arterial dysplasia, and anomalous origin of the right coronary artery is unique.

Intramyocardial arterial narrowing in dogs with subaortic stenosis

Earlier studies have described intramyocardial arterial narrowing based on hyperplasia and hypertrophy of the vessel wall in dogs with subaortic stenosis (SAS). In theory, such changes might increase the risk of sudden death, as they seem to do in heart disease in other species. This retrospective pathological study describes and quantifies intramyocardial arterial narrowing in 44 dogs with naturally occurring SAS and in eight control dogs. The majority of the dogs with SAS died suddenly (n=27); nine had died or been euthanased with signs of heart failure and eight were euthanased without clinical signs. Dogs with SAS had significantly narrower intramyocardial arteries (P<0.001) and more myocardial fibrosis (P<0.001) than control dogs. Male dogs and those with more severe hypertrophy had more vessel narrowing (P=0.02 and P=0.02, respectively), whereas dogs with dilated hearts had slightly less pronounced arterial thickening (P=0.01). Arterial narrowing was not related to age, but fibrosis increased with age (P=0.047). Dogs that died suddenly did not have a greater number of arterial changes than other dogs with SAS. This study suggests that most dogs with SAS have intramyocardial arterial narrowing and that the risk of dying suddenly is not significantly related to the overall degree of vessel obliteration.

Cardiac arteriovenous malformation causing sudden death

Cardiac vascular malformations are rare. We report a subendocardial arteriovenous malformation (AVM), associated with extensive myocardial fibrosis, causing sudden death in a 25-year-old woman. To our knowledge, this is the first autopsy case reported.

Subendocardial small infarct in the superior ventricular septum as a cause of sudden death

In autopsy files from April 1999 to April 2001, five cases showed macroscopic subendocardial small infarct above 1 cm diameter in the superior ventricular septum (SVS) near the atrioventricular (AV) junction, and all five were finally considered to be sudden cardiac death after full investigation. All these small infarcts in these Japanese patients were located at the posterior site of the SVS, an area mainly nourished by branches which ramified from the AV node artery and which branched from the right coronary artery (RCA). Four of the five showed acute (A) or subacute (SA) foci in or around the healed (H) lesion and surviving myocytes were visible in infarcts, in all cases, which suggested a recurrent or chronic prolonged ischemia in the territory. Four of the five had a significant stenosis of the RCA and in the other one, there was an anomalous origin of the RCA. As all five had also small artery disease in the SVS, small infarct of the posterior SVS may have formed by hemodynamic impairment in the territory of the AV node artery caused by RCA disorders. We consider the evidence of macroscopic small infarct of the posterior SVS greatly aids in determining the cause of sudden death in forensic autopsy and may be notable lesion for discussing the pathogenesis of sudden cardiac death with RCA disorder.

Conduction system abnormalities in alcoholics with asymptomatic valvular disease who suffer sudden death

We examined the cardiac conduction system of three alcohol abusers who died suddenly. Cases 1 and 2 showed mitral valve disorder (mitral valve prolapse and rheumatic valvular disease), while Case 3 showed mild Ebstein's anomaly. On examination of the conduction system, Cases 1 and 2 showed severe fibrofatty infiltration into the conduction system, and we conclude that these findings were probably a complication of alcohol abuse. Both cases also demonstrated severe small artery disease. The conduction system of Case 3 showed an anomalous location of the bundle of His with its fragmentation. These three cases suggest that such considerable conduction system abnormalities may be significant findings in alcohol abusers with valvular disease. We consider that alcohol intake may be one of the direct accelerating factors for arrhythmogenic potential to the abnormal conduction system in alcohol abusers who have asymptomatic valvular disease.

Fibromuscular dysplasia of coronary arteries resulting in myocardial infarction associated with hypertrophic cardiomyopathy in Noonan's syndrome

The first autopsy case of fibromuscular dysplasia in the coronary arteries associated with hypertrophic cardiomyopathy in Noonan's syndrome is reported. A 16-month-old female infant with no significant family history was diagnosed with Noonan's syndrome and subsequently died of cardiac and respiratory failure. Autopsy revealed cardiac hypertrophy, atrial septal defect, and scar lesions in the left ventricle and ventricular septum. Histologically, the myocardium exhibited myocardial fiber disarray, which was indicative of hypertrophic cardiomyopathy. The main trunks of the coronary arteries showed protuberant intimal thickening with interruption of the internal elastic lamina. Intramyocardial coronary arteries also exhibited various degrees of irregular intimal proliferation and diffuse fibrous thickening of the adventitia. These arterial lesions were consistent with fibromuscular dysplasia. Small arteries around the scar showed remarkable stenoses, which probably led to myocardial ischemia. The fibromuscular dysplasia in this case was considered to arise as a cardiovascular disorder in conjunction with Noonan's syndrome.

Sudden death related to small coronary artery disease

Two cases of sudden death of young people in apparently good health are reported. The only pathologic change found was a fibromuscular dysplasia of the artery supplying the conduction system of the heart with an important narrowing of the lumen and strong thickening of the arterial wall. The first case was of a 12-year-old girl who died suddenly while skiing; the second was of a 32-year-old man who died while talking to his wife. No other pathologic changes were found at autopsy, and the results of toxicologic analysis were negative. There was no individual or family history of cardiac diseases. These cases illustrate the importance of an analysis of the conduction system, including examination of the intramural coronary arteries supplying the conduction system.