Chronologic electrocardiographic changes in patients with hypertrophic cardiomyopathy associated with cardiac troponin 1 mutation

Phenotype variation of hypertrophic cardiomyopathy in carriers of the p.Arg870His pathogenic variant in the MYH7 gene

The review analyzes variability of clinical manifestations of p.Arg870His in the MYH7 gene, which is repeatedly registered in patients with hypertrophic cardiomyopathy (HCM). The analysis involves the data from scientific publications obtained as a search result in the PubMed, СlinVar, and eLibrary.ru databases, as well as authors’ own results. A wide range of phenotypic manifestations have been revealed in carriers of p.Arg870His, from the asymptomatic to severe course, rapid progression, and early death. The review considers possible factors that modify the effect of the pathogenic variant (i.e. dosage of the pathogenic variant, the presence of other unfavorable genetic variants, etc.). The importance of accumulating information on the clinical features of HCM in the carriers of specific gene variants is emphasized in order to clarify their pathogenicity and to identify factors modifying the clinical outcome, which is important for the choice of the treatment strategy for HCM.

Conduction system pacing versus biventricular pacing: Reduced repolarization heterogeneity in addition to improved depolarization

INTRODUCTION

His-bundle pacing (HBP) and left-bundle-area pacing (LBAP) are conduction system pacing (CSP) modalities increasingly used as alternatives to conventional biventricular pacing (BiVP). While effects of CSP on ventricular depolarization have been reported, effects on ventricular repolarization have not.

METHODS

QRS duration (QRSd) and validated ECG parameters of ventricular repolarization associated with arrhythmic risk (T-peak-to-T-end_Transmural , T-peak-to-T-end_Total , T-peak dispersion, QTc, QTc dispersion) were analyzed post-implant in 107 patients: 60 with CSP (HBP: n = 35, LBAP: n = 25) and 47 with BiVP. T-wave memory resolution and QTc shortening were analyzed on ECGs obtained ≥25 days post-implant. Twenty blinded measurements were obtained by both authors to assess Interobserver variability.

RESULTS

Although QRSd was shorter with HBP versus LBAP (119 ± 7 ms vs. 132 ± 9 ms, p = .02), there were no significant differences in any repolarization parameters between these methods of CSP. However, when comparing CSP (HBP + LBAP) to BiVP, both QRSd (125 ± 5 ms vs. 147 ± 7 ms, p < .0001) and repolarization parameters (T-peak-to-T-end_Transmural : 83 ± 5 ms vs. 107 ± 8 ms; T-peak-to-T-end_Total : 110 ± 7 ms vs. 137 ± 10 ms; QTc: 470 ± 12 ms vs. 506 ± 12 ms; all p ≤ .0001) were significantly shorter with CSP. Improved T-peak-to-T-end values were unrelated to pre-implant QRSd or LV function. Interobserver variability was 4.6 ± 1.9 ms. Frontal QRS-T angle narrowing (132° to 104°, p = .001) and QTc shortening (483 ± 13 ms to 464 ± 12 ms, p = .008) were seen only with CSP.

CONCLUSIONS

In addition to improved depolarization, CSP reduced repolarization heterogeneity and provided greater T-wave memory resolution as compared to BiVP. Both modalities of CSP (HBP + LBAP) resulted in comparably reduced repolarization heterogeneity regardless of baseline QRSd and LV function. These observations may confer lower arrhythmogenic risk and warrant further study.

Overlap phenotypes of the left ventricular noncompaction and hypertrophic cardiomyopathy with complex arrhythmias and heart failure induced by the novel truncated DSC2 mutation

Background

The left ventricular noncompaction cardiomyopathy (LVNC) is a rare subtype of cardiomyopathy associated with a high risk of heart failure (HF), thromboembolism, arrhythmia, and sudden cardiac death.

Methods

The proband with overlap phenotypes of LVNC and hypertrophic cardiomyopathy (HCM) complicates atrial fibrillation (AF), ventricular tachycardia (VT), and HF due to the diffuse myocardial lesion, which were diagnosed by electrocardiogram, echocardiogram and cardiac magnetic resonance imaging. Peripheral blood was collected from the proband and his relatives. DNA was extracted from the peripheral blood of proband for high-throughput target capture sequencing. The Sanger sequence verified the variants. The protein was extracted from the skin of the proband and healthy volunteer. The expression difference of desmocollin2 was detected by Western blot.

Results

The novel heterozygous truncated mutation (p.K47Rfs*2) of the DSC2 gene encoding an important component of desmosomes was detected by targeted capture sequencing. The western blots showed that the expressing level of functional desmocollin2 protein (~ 94kd) was lower in the proband than that in the healthy volunteer, indicating that DSC2 p.K47Rfs*2 obviously reduced the functional desmocollin2 protein expression in the proband.

Conclusion

The heterozygous DSC2 p.K47Rfs*2 remarkably and abnormally reduced the functional desmocollin2 expression, which may potentially induce the overlap phenotypes of LVNC and HCM, complicating AF, VT, and HF.

Syncope and electrocardiogram

INTRODUCTION

Suspected transient loss of consciousness (T-LOC) and syncope are common causes of hospitalization in older patients. Arrhythmias are the most common cardiac causes of syncope. Although a number of instrumental diagnostic procedures are usually routinely performed in patients with suspected syncope, a 12 leads electrocardiogram (ECG) is the only instrumental test recommended for the initial evaluation of these patients.

EVIDENCE ACQUISITION

In this paper current literature on this topic will be reviewed, including ECG diagnostic criteria and findings suggestive of cardiac syncope.

EVIDENCE SYNTHESIS

The ECG may disclose an arrhythmia associated with a high likelihood of syncope, avoiding further evaluations and permitting institution of specific treatment in 7% of patients referred to emergency department. When the cause of syncope remains uncertain after initial evaluation the next step is to assess the risk of major cardiovascular events or sudden cardiac death. An abnormal ECG selected patients with high probabiliry of cardiac syncope. ECG diagnostic criteria and ECG findings suggesting arrhythmic syncope are presented. Indications and potential clinical implications of ECG monitoring will be discussed too.

CONCLUSIONS

A careful, well-conducted medical history focused on the suspected syncopal event is crucial for the diagnosis. In this setting, the ECG is a mandatory diagnostic tool which, although normal in the majority of patients of syncope, has the potential to identify patients with high likelihood of cardiac syncope due to arrhythmic or cardiopulmonary disorder.

Novel electrocardiographic features in carriers of hypertrophic cardiomyopathy causing sarcomeric mutations

OBJECTIVES

The sensitivity and specificity of the conventional 12-lead ECG to identify carriers of hypertrophic cardiomyopathy (HCM) - causing mutations without left ventricular hypertrophy (LVH) has been limited. We assessed the ability of novel electrocardiographic parameters to improve the detection of HCM mutation carriers.

METHODS

We studied 140 carriers (G+) of the TPM1-Asp175Asn or MYBPC3-Gln1061X pathogenic variants for HCM: The G+/LVH+ group (n = 98) consisted of mutation carriers with LVH and the G+/LVH- group (n = 42) without LVH. The control group consisted of 30 subjects. The standard 12-lead ECG was comprehensively analyzed and two novel ECG variables were introduced: RV1<RV2>RV3 and septal remodeling. A subset of 65 individuals underwent cardiac magnetic resonance imaging and 2D strain echocardiography.

RESULTS

Conventional major ECG criteria were sensitive (90%) and specific (97%) in identifying G+/LVH+ subjects. RV1<RV2>RV3 and septal remodeling were more prevalent in the G+/LVH- subjects compared to the control group (33% vs 3%, p = 0.005 and 45% vs 3%, p < 0.001, respectively). The combination of RV1<RV2>RV3 and Q waves and repolarization abnormalities (QR) differentiated between the G+/LVH- subjects and the control group with a sensitivity of 52% and specificity of 97%. The combination of septal remodeling and QR differentiated between G+/LVH- subjects and the control group with a sensitivity of 64% and specificity of 97%.

CONCLUSIONS

The novel ECG-parameters RV1<RV2>RV3 and septal remodeling were effective in identifying G+/LVH- subjects and could be useful in the diagnostics of new suspected HCM patients and in the screening and follow-up of HCM families.

Pre-participation examination of competitive athletes: role of the ECG

Sudden cardiac death in athletes is rare but has a wide social impact because it confronts the general population with the paradox that athletes perceived and admired as the fittest and healthiest suddenly drop dead during their sport. Mass media coverage is guaranteed in the case of sudden cardiac death of a top athlete, while other competitive and noncompetitive athletes of all ages, team members, sponsors, as well as huge parts of society remain puzzled and frightened. Therefore, debate is ongoing regarding how to minimize the number of fatalities, and the search continues for a cost-effective preparticipation screening for competitive athletes. Despite the fact that routine ECG screening would be widely available and rather inexpensive, debate continues regarding whether this should be part of initial screening for every athlete before starting to train at high intensity as well as during annual checkups. The role of ECGs in preparticipation examinations of competitive athletes is intensively discussed because there is a lack of strict criteria for which ECG findings should generate further workup. In this article, we analyze the main publications on sudden cardiac death, focusing on the benefit of ECG screening in preparticipation examination as it has been shown to be feasible and effective in identifying athletes at risk of sudden cardiac death.

Impact of QT variables on clinical outcome of genotyped hypertrophic cardiomyopathy

BACKGROUND

Although QT variables such as its interval and/or dispersion can be clinical markers of ventricular tachyarrhythmia, few data exist regarding the role of QT variables in genotyped hypertrophic cardiomyopathy (HCM). Therefore, we analyzed QT variables in genotyped subjects with or without left ventricular hypertrophy (LVH).

METHODS

QT variables were analyzed in 111 mutation and 43 non-mutation carriers who were divided into three groups: A, those without ECG abnormalities and echocardiographically determined LVH (wall thickness > or =13 mm); B, those with ECG abnormalities but LVH; and C, those with ECG abnormalities and LVH. We also examined clinical outcome of enrolled patients.

RESULTS

Maximal LV wall thickness in group C (19.0 +/- 4.3 mm, mean +/-SD) was significantly greater than that in group A (9.2 +/- 1.8) and group B (10.4 +/- 1.8). Under these conditions, maximum QTc interval and QT dispersion were significantly longer in group C than those in group A (438 +/- 38 ms vs 406 +/- 30 and 64 +/- 31 vs 44 +/- 18, respectively; P < 0.05). QTc interval and QT dispersion in group B (436 +/- 50 and 64 +/- 22 ms) were also significantly greater than those in group A. During follow-up periods, four sudden cardiac deaths and one ventricular fibrillation were observed in group C, and two nonlethal ventricular tachyarrhythmias were observed in group B.

CONCLUSIONS

Patients with HCM-related gene mutation accompanying any ECG abnormalities frequently exhibited impaired QT variables even without LVH. We suggest that careful observation should be considered for those genotyped subjects.

The electrocardiogram in the patient with syncope

Syncope is a common and challenging presentation for the emergency physician. Various investigators have developed clinical risk score and clinical decision rules which are designed to identify the population at highest risk for adverse events. In each of these clinical decision tools, the electrocardiogram (ECG) is one of the key clinical variables used to evaluate the patient. Certain electrocardiographic presentations in the patient with syncope will not only provide a reason for the loss of consciousness but also guide early therapy and disposition in this individual. Bradycardia, atrioventricular block, intraventricular conduction abnormality, and tachydysrhythmia in the appropriate clinical setting provide an answer to the clinician for the syncopal event. Morphologic findings suggesting the range of cardiovascular malady are also encountered; these entities are far ranging, including the various ST-segment and T-wave abnormalities of acute coronary syndrome, ventricular preexcitation as seen in the Wolff-Parkinson-White syndrome, Brugada syndrome with the associated tendency for sudden death, prolonged QT interval common in the diverse long QT interval presentations, and right ventricular hypertrophy suggestive of hypertrophic cardiomyopathy. This review discusses the ECG in the patient with syncope. The general use of the 12-lead ECG in this patient population is discussed. Furthermore, specific electrocardiographic presentations seen in the patient with syncope are also reviewed.

Differences in the diagnostic value of various criteria of negative T waves for hypertrophic cardiomyopathy based on a molecular genetic diagnosis

Differences in the diagnostic value of a variety of definitions of negative T waves for HCM (hypertrophic cardiomyopathy) have not yet been clarified, resulting in a number of definitions being applied in previous studies. The aim of the present study was to determine the most accurate diagnostic definition of negative T waves for HCM in genotyped populations. Electrocardiographic and echocardiographic findings were analysed in 161 genotyped subjects (97 carriers and 64 non-carriers). We applied three different criteria that have been used in previous studies: Criterion 1, negative T wave >10 mm in depth in any leads; Criterion 2, negative T wave >3 mm in depth in at least two leads; and Criterion 3, negative T wave >1 mm in depth in at least two leads. Of the three criteria, Criterion 3 had the highest sensitivity (43% compared with 5 and 26% in Criterion 1 and Criterion 2 respectively; P<0.0001) and retained a specificity of 95%, resulting in the highest accuracy. In comparison with abnormal Q waves, negative T waves for Criterion 3 had a lower sensitivity in detecting carriers without LVH (left ventricular hypertrophy) (12.9% for negative T waves compared with 22.6% for abnormal Q waves). On the other hand, in detecting carriers with LVH, the sensitivity of negative T waves increased in a stepwise direction with the increasing extent of LVH (P<0.001), whereas there was less association between the sensitivity of abnormal Q waves and the extent of LVH. In conclusion, Criterion 3 for negative T waves may be the most accurate definition of HCM based on genetic diagnoses. Negative T waves may show different diagnostic value according to the different criteria and phenotypes in genotyped populations with HCM.

Hypertrophic cardiomyopathy: electrocardiographic manifestations and other important considerations for the emergency physician

Hypertrophic cardiomyopathy (HCM) is one of the most common inherited primary cardiac disorders and the most common cause of sudden cardiac death in young athletes. With advances in technology, it is now recognized that HCM affects individuals of all ages. Many patients with HCM will have a benign course with few symptoms. Some patients, however, possess risk factors that greatly increase the likelihood of sudden death if their disease remains undiagnosed. Therefore, it is imperative that emergency physicians be familiar with the symptoms and typical electrocardiogram manifestations of HCM. Three illustrative cases are presented with a review of the disease.

Utility of cardiac magnetic resonance imaging in the diagnosis of hypertrophic cardiomyopathy

BACKGROUND

Two-dimensional echocardiography is currently the standard test for the clinical diagnosis of hypertrophic cardiomyopathy (HCM). The present study was undertaken to determine whether cardiac MRI (CMR) affords greater accuracy than echocardiography in establishing the diagnosis and assessing the magnitude of left ventricular (LV) hypertrophy in HCM.

METHODS AND RESULTS

Forty-eight patients (age 34+/-16 years) suspected of having HCM (or with a confirmed diagnosis) were imaged by both echocardiography and CMR to assess LV wall thickness in 8 anatomic segments (total n=384 segments) and compared in a blinded fashion. Maximum LV thickness was similar by echocardiography (21.7+/-9.1 mm) and CMR (22.5+/-9.6 mm; P=0.21). However, in 3 (6%) of the 48 patients, echocardiography did not demonstrate LV hypertrophy, and CMR identified otherwise undetected areas of wall thickening in the anterolateral LV free wall (17 to 20 mm), which resulted in a new diagnosis of HCM. In the overall study group, compared with CMR, echocardiography also underestimated the magnitude of hypertrophy in the basal anterolateral free wall (by 20+/-6%; P=0.001), as well as the presence of extreme LV wall thickness (> or =30 mm) in 10% of patients (P<0.05).

CONCLUSIONS

CMR is capable of identifying regions of LV hypertrophy not readily recognized by echocardiography and was solely responsible for diagnosis of the HCM phenotype in an important minority of patients. CMR enhances the assessment of LV hypertrophy, particularly in the anterolateral LV free wall, and represents a powerful supplemental imaging test with distinct diagnostic advantages for selected HCM patients.

Resting ST-segment depression predicts exercise-induced subendocardial ischemia in patients with hypertrophic cardiomyopathy

BACKGROUND

Patients with hypertrophic cardiomyopathy (HCM) sometimes display characteristic electrocardiographic (ECG) findings at rest and develop subendocardial ischemia during exercise in the absence of coronary lesions. However, their relationship has not yet been fully clarified.

METHODS

Exercise Tc-99m-tetrofosmin myocardial scintigraphy was performed in 48 patients with non-obstructive HCM. We quantified transient left ventricular cavity dilation (LVCD) on exercise scintigrams, a parameter of subendocardial ischemia, and correlated the results with the ECG findings at rest and during exercise.

RESULTS

Transient LVCD occurred during exercise in 17 (35%) patients with HCM. Hemodynamic parameters during exercise did not differ between HCM patients with and without transient LVCD. Multiple logistic regression analysis showed that transient LVCD was significantly associated with ST-segment depression at rest (chi2=5.00, odds ratio=5.70, 95% confidence intervals 1.24-26.18, P=0.025) and a greater total number of leads with resting ST-segment depression (chi2=6.38, odds ratio=1.60, 95% confidence intervals 1.12-2.42, P=0.012). The degree of LVCD was correlated with the total number of leads with ST-segment depression at rest (P=0.002); the optimal cutoff for the diagnosis of transient LVCD was 3 with a sensitivity of 65%, a specificity of 90%, and an accuracy of 81%.

CONCLUSIONS

In patients with HCM, ST-segment depression at rest was accompanied by exercise-induced subendocardial perfusion abnormality as detected by myocardial scintigraphy. ST-segment depression at rest suggests that the subendocardium is predisposed to exertional ischemia.

A novel mutation in the cardiac myosin-binding protein C gene is responsible for hypertrophic cardiomyopathy with severe ventricular hypertrophy and sudden death

It has been demonstrated previously that clinical phenotypes of HCM (hypertrophic cardiomyopathy) caused by mutations in the cardiac MyBP-C (myosin-binding protein C) gene show late onset, low penetrance and favourable clinical course. However, we have encountered severe phenotypes in several carriers of the MyBP-C gene mutations. The aim of the present study was to screen novel MyBP-C gene mutations in patients with HCM and to investigate the genetic differences in affected subjects with severe phenotypes. The MyBP-C gene was screened in 292 Japanese probands with HCM, and a novel c.2067+1G→A mutation was present in 15 subjects in five families. Clinical phenotypes of carriers of the c.2067+1G→A mutation were compared with those of a previously identified Arg820Gln (Arg820→Gln) mutation in the MyBP-C gene. The disease penetrance in subjects aged ≥30 years was 90% in carriers of the c.2067+1G→A mutation and 61% in carriers of the Arg820Gln mutation. Sudden death occurred in four subjects from three families with the c.2067+1G→A mutation and in two subjects from one family with the Arg820Gln mutation. Two carriers of the c.2067+1G→A mutation had substantial hypertrophy (maximal wall thickness ≥30 mm). In contrast, two carriers of the Arg820Gln mutation had end-stage HCM. In conclusion, the c.2067+1G→A mutation is associated with HCM with substantial hypertrophy and moderate incidence of sudden death, whereas the Arg820Gln mutation is associated with end-stage HCM. These observations may provide important prognostic information regarding the clinical practice of HCM.

Differences in diagnostic value of four electrocardiographic voltage criteria for hypertrophic cardiomyopathy in a genotyped population

The diagnostic value of various classic electrocardiographic (ECG) voltage criteria for hypertrophic cardiomyopathy (HC) has not been established in a genotyped population. This study aimed to determine the most accurate diagnostic definition of classic ECG voltage criteria for detecting carriers of HC. ECG and echocardiographic findings were analyzed in 161 genotyped subjects (97 genetically affected, 64 unaffected) from 20 families with disease-causing mutations in 4 genes. The diagnostic value of 4 voltage criteria (Cornell, Sokolow-Lyon, Romhilt-Estes, and 12-lead QRS voltage) for detecting carriers of HC was investigated. In all subjects, the Romhilt-Estes (point score > or =4) criterion and 12-lead QRS voltage (> or =240 mm) were most sensitive (37% and 36%, respectively), with high specificity (95% each), resulting in the greatest accuracy (60% and 59%, respectively). Using these criteria, in subjects without echocardiographic evidence of left ventricular hypertrophy, voltage abnormalities were found in 22.6% of carriers and 4.7% of noncarriers (p <0.01). In conclusion, these findings suggest that the Romhilt-Estes and the 12-lead QRS voltage criteria may be the most accurate diagnostic definitions for HC on the basis of molecular genetic diagnoses. Furthermore, this study demonstrated that voltage abnormalities may be found in prehypertrophic carriers. Even when genetic testing becomes widely available, it will be difficult to make genetic diagnoses in all patients with HC because of its genetic heterogeneity. Therefore, understanding the diagnostic value of classic ECG voltage criteria may be important in detecting carriers, including those without left ventricular hypertrophy.

Phenotypic differences between electrocardiographic and echocardiographic determination of hypertrophic cardiomyopathy in genetically affected subjects

OBJECTIVES

In the molecular era, two types of phenotypic differences are recognized between electrocardiography (ECG) and echocardiography in hypertrophic cardiomyopathy (HCM); ECG abnormalities in carriers without left ventricular hypertrophy (LVH), and normal ECG patterns in carriers with LVH. The goal of this study was to evaluate the diagnostic value of ECG for detecting carriers without LVH, and also to assess normal ECG patterns in carriers with LVH from the genetic standpoint of HCM.

SETTING

A matched case-control study in a university hospital and general hospitals in Japan.

PATIENTS AND DESIGN

ECG and echocardiographic findings were analysed in 173 genotyped subjects (107 genetically affected, 66 unaffected) from families with disease-causing mutations in four genes.

RESULTS

ECG abnormalities were found in 18 (54.5%) of 33 nonhypertrophic carriers, but only nine (13.6%) of 66 noncarriers (P < 0.001). For detecting nonhypertrophic carriers, ST-T abnormalities showed the highest accuracy amongst the three major ECG criteria. In contrast, normal ECG patterns were found in eight (10.8%) of 74 carriers with LVH. The sensitivity of ECG for detecting carriers with LVH in families with the cardiac myosin-binding protein C, cardiac troponin T and cardiac troponin I gene mutations was 83%, 88% and 94% respectively.

CONCLUSION

These findings suggest that ECG may have favourable diagnostic value even for detecting nonhypertrophic carriers. Furthermore, diagnostic value of ECG may differ according to the genes involved. Our data may contribute to interpretation of phenotypic differences between ECG and echocardiography from the viewpoint of molecular genetics of HCM.

Ventricular fibrillation refractory to ICD therapy

A 14-year-old boy was admitted for the evaluation of recurrent syncope. His ECG on admission revealed a sinus rhythm with an undetermined QRS axis, T wave inversion at leads V3, V4 and abnormal q at leads I, aVL, V5 and V6. However, no underlying disease could be detected by any morphological examination. Programmed ventricular stimulation also induced no ventricular tachycardia or fibrillation (VF). Only signal-averaged ECG showed ventricular late potential and the cause of syncope was not clarified. As his brother with a similar ECG had died suddenly, he was prophylactically treated with an ICD. However, 14 months later he died suddenly after playing a video game. The ICD recorded VF, which was not converted despite 6 cardioversion attempts by the ICD. Progression of myocardial damages and/or elevation of defibrillation threshold may have been the cause of unsuccessful cardioversion.

Inherited cardiomyopathies as a troponin disease

Troponin, one of the sarcomeric proteins, plays a central role in the Ca(2+) regulation of contraction in vertebrate skeletal and cardiac muscles. It consists of three subunits with distinct structure and function, troponin T, troponin I, and troponin C, and their accurate and complex intermolecular interaction in response to the rapid rise and fall of Ca(2+) in cardiomyocytes plays a key role in maintaining the normal cardiac pump function. More than 200 mutations in the cardiac sarcomeric proteins, including myosin heavy and light chains, actin, troponin, tropomyosin, myosin-binding protein-C, and titin/connectin, have been found to cause various types of cardiomyopathy in human since 1990, and more than 60 mutations in human cardiac troponin subunits have been identified in dilated, hypertrophic, and restrictive forms of cardiomyopathy. In this review, we have focused on the mutations in the genes for human cardiac troponin subunits and discussed their functional consequences that might be involved in the primary mechanisms for the pathogenesis of these different types of cardiomyopathy.

Electronic medical devices: a primer for pathologists

CONTEXT

Electronic medical devices (EMDs) with downloadable memories, such as implantable cardiac pacemakers, defibrillators, drug pumps, insulin pumps, and glucose monitors, are now an integral part of routine medical practice in the United States, and functional organ replacements, such as the artificial heart, pancreas, and retina, will most likely become commonplace in the near future. Often, EMDs end up in the hands of the pathologist as a surgical specimen or at autopsy. No established guidelines for systematic examination and reporting or comprehensive reviews of EMDs currently exist for the pathologist.

OBJECTIVE

To provide pathologists with a general overview of EMDs, including a brief history; epidemiology; essential technical aspects, indications, contraindications, and complications of selected devices; potential applications in pathology; relevant government regulations; and suggested examination and reporting guidelines.

DATA SOURCES

Articles indexed on PubMed of the National Library of Medicine, various medical and history of medicine textbooks, US Food and Drug Administration publications and product information, and specifications provided by device manufacturers.

STUDY SELECTION

Studies were selected on the basis of relevance to the study objectives.

DATA EXTRACTION

Descriptive data were selected by the author.

DATA SYNTHESIS

Suggested examination and reporting guidelines for EMDs received as surgical specimens and retrieved at autopsy.

CONCLUSIONS

Electronic medical devices received as surgical specimens and retrieved at autopsy are increasing in number and level of sophistication. They should be systematically examined and reported, should have electronic memories downloaded when indicated, will help pathologists answer more questions with greater certainty, and should become an integral part of the formal knowledge base, research focus, training, and practice of pathology.