Sudden death in an adult with a small ventricular septal defect and an aneurysmal membranous septum

Arrhythmias in adult congenital heart disease

Recent advances in pediatric cardiology and cardiac surgery have allowed a rapidly expanding population of patients with congenital heart disease to thrive well into their adult years. Often after prolonged uneventful clinical courses as children and adolescents, arrhythmias may surface later in life. These arrhythmias are a major source of morbidity. In addition, sudden death is the leading cause of mortality in adult patients with congenital heart disease. This review highlights the various types of brady- and tachyarrhythmias encountered in the more common forms of adult congenital heart disease and explores prognostic implications and therapeutic options.

Pseudoaneurysm of the membranous septum, case report and review of the literature

Pseudoaneurysm (dissecting aneurysm) of the membranous septum is a rare occasion. Clinically, aneurysms and pseudoaneurysms not only have the potential to reduce ventricular size, but also can be further complicated by rupture of the aneurysm and by promoting tricuspid insufficiency, aortic valve prolapse, ventricular outflow tract obstruction, and bacterial endocarditis. We describe a case in which a pseudoaneurysm of the membranous septum was identified protruding into the left outflow tract.

Sudden cardiac death in younger adults: autopsy diagnosis as a tool for preventive medicine

Sudden death in children and younger adults can be caused by potentially heritable cardiovascular disorders, and the fatal outcome is often the first symptom in apparently healthy subjects. In these cases, a careful autopsy becomes the sole diagnostic tool to guide the clinical screening of the families. The aims of the present study were (1) to assess the pathological substrate of sudden cardiac death in children and younger adults (age, 1-40 years) in a large prospective series using strict morphological criteria; and (2) to perform cardiological assessment of the relatives of the deceased subjects with cardiomyopathies or structurally normal hearts, potentially consistent with a heritable cardiac disease. We studied 100 consecutive cases. Autopsy findings included coronary artery disease (30%, atherosclerotic in the majority of cases), cardiomyopathies (22%), and various cardiac abnormalities (28%). In the remaining 20% of cases, the presence of significant morphological abnormalities of the heart was ruled out. Twenty of 42 families in which the heart of the proband was either affected by a cardiomyopathy or failed to show significant structural abnormalities could be contacted and provided informed consent to cardiological assessment. A potentially inherited cardiac disease was diagnosed in 4 (20%). Molecular genetic analysis was restricted to 3 of these families and revealed a mutation in the ryanodine receptor type 2 gene (RyR2) in 1. Our results underline the implication of autopsy findings for relatives and the importance of cardiological screening of family members to uncover familial cardiomyopathies or genetic arrhythmias and to adopt the proper therapeutic and preventive strategies. Genetic testing is still time consuming and costly: accordingly, it should be restricted only to selected cases.

Ventricular septal defect and multiple aneurysms

A 41-year-old man with a small perimembranous ventricular septal defect (VSD) developed aneurysms and aortic elongation, tortuosity and dissecting aneurysm. The asymptomatic VSD, without pulmonary circulatory disturbance, was considered hemodynamically benign and too small to warrant surgical closure. However, prolonged strenuous sporting activities could have potentiated premature development of aortic sclerosis and the unusual vascular lesions secondary to the VSD, and an injury may have precipitated mural dissection in the vulnerable aortic wall. Clinicopathological analysis of the unusual complications associated with the VSD suggests that closure of the defect at an early age should be considered to possibly obviate premature degenerative, valvular and vascular changes in adulthood and also secondary endocardial infection.

A postmortem review of congenital cardiac malformations in a series of 180 adults, over the age of 16 years, born between 1865 and 1980

The evolution of diagnosis and treatment of congenital heart malformations can be traced through patients surviving into adulthood. We reviewed the heart specimens from 180 patients aged 16 to 86 years and considered the morphological features, the nature of any interventional procedures, and the events leading to death. Based on the mode of clinical presentation, 33 cases were considered covert, and the remaining 147 cases were known or suspected to have a cardiac abnormality during life. Of the symptomatic cases, 60 had no surgical intervention, whereas 167 surgical procedures had been performed in the remaining 87 cases. Acquired heart disease was noted in 7 of the covert cases and in 16 of the symptomatic cases. Overall, there were only 3 instances of errors in clinical identification of significant morphological abnormalities, and 2 cases related to surgical procedures. This review emphasizes the value of autopsy examination for clinicopathologic correlations and the case for retention of cardiac specimens for teaching purposes.