Cardiac Findings of Pulmonary Thromboembolism by Autopsy: A Review of 48 Cases

Forensic Pathological Analysis of Death Due to Pulmonary Thromboembolism: A Retrospective Study Based on 145 Cases

ABSTRACT

Pulmonary thromboembolism (PTE) is a common cause of sudden unexpected death in forensic and clinical practice. Although the prevention of thrombosis has been paid more attention in clinical practice in recent years, the number of deaths due to PTE remains extensive. In the present study, 145 cases of fatal PTE were collected and retrospectively analyzed from 2001 to 2020 at the School of Forensic Medicine, China Medical University in Liaoning Province, northeast of China. The demographic characteristics, risk factors of PTE, origins of thrombi, and time interval from the occurrence of main risk factors to PTE were retrospectively analyzed. The 40 to 59 age group accounted for the 51.0% of the total cases. Immobilization, trauma (especially fracture of the pelvis, femur, tibia, or fibula), surgery, cesarean section, and mental disorders were the top 5 high-risk factors. Among the involved cases, 92.9% of the PTE (130/140) occurred within 60 days and peak at 8 to 15 days after the exposure of main risk factors. According to the autopsy findings, 87.6% of the thrombi blocked the bilateral pulmonary arteries at pulmonary hilus, with a maximum diameter of 1.6 cm and a maximum length of 21.9 cm, which were mainly derived from lower limb (65.5%) or pelvic veins (10.3%). Although the embolus limited the pulmonary circulation, there is no difference on the ratio of lung-to-heart weight between PTE and the disease-free accident victims. Overall, our present retrospective study provides important information for the forensic analysis on the cause of death and potential guidance on clinical prevention of PTE.

Clinical factors associated with massive pulmonary embolism and PE-related adverse clinical events

Background

Clinicians evaluating acute PE patients often have to identify risks for massive PE, a measure of hemodynamic instability and its consequence, massive PE related adverse clinical events (PEACE). We investigated the association of these risk factors with massive PE and PEACE in a consecutive PE cohort (n = 364).

Methods

Massive PE was defined as an acute central clot (proximal to the lobar artery) in a patient with right heart strain and systolic blood pressure ≤ 90 mg. PEACE was defined as any massive PE who died or required one or more of the following: ACLS, assisted ventilation, vasopressor use, thrombolytic therapy, or invasive thrombectomy, within seven days of PE diagnosis. Univariate and multivariate analysis assessing associations between the risk factors (age, gender, comorbidities, PE provoking risks, and whether the PE was felt to be idiopathic) and massive PE or PEACE were performed. Significance was determined at p < 0.05.

Results

Thirteen percent (n = 48) of patients presented with massive PE, and 9% (n = 32) had PEACE. In the final multivariate model, recent invasive procedure (RR = 7.4, p = 0.007), recent hospitalization (RR = 7.3, p = 0.002), and idiopathic PE (RR = 6.5, p = 0.003) were associated with massive PE. Only idiopathic PE (RR = 5.7, p = 0.005) was significantly associated with PEACE. No comorbidities or other PE provoking risks were associated with massive PE or PEACE.

Conclusions

As a take-home message, recent invasive procedure, recent hospitalization, and idiopathic PE were associated with massive PE, and only idiopathic PE was associated with PEACE. Simultaneously, comorbidities like age or chronic cardiopulmonary disease seem not to be associated with massive PE or PEACE.