心脏传导系统变异及发育异常(讲座2)

心脏传导系统变异与发育异常是完全不同的两个概念 ,前者是属个体间的形态差异系生理性变化 ,后者是属病理性畸形 ,划清这两种界线对一个基层法医工作者有着重要的实用意义。1　CCS的变异CCS与人体其它系统、器官一样 ,亦具有某些形态变异 ,这些变异并不影响CCS的正常功能。根据产生变异的机理可分两种 :( 1)个体发育差异 :变异 (Variation)是指正常心脏的CCS位置或形态学的个体差异。表现为过大、过小 (正常中国人窦房结 10～ 15mm× 3～ 5mm× 1～ 2mm、房室结 8mm×4mm× 1mm、房室束 1mm× 1mm× 2 0mm )、变形 (如房室结变成薄片…     

房室结纤维和脂肪增多与房室结动脉狭窄的关系

目的探讨房室结纤维、脂肪含量与房室结动脉狭窄之间的关系,分析房室结内病理性纤维化和病理性脂肪浸润的原因。方法选取119例心源性猝死案例,用Image-pro plus图像分析软件检测组织切片,计算房室结面积,房室结动脉内径、房室结动脉管腔面积(lumen area,LA)、外周横截面积(perimeterarea,PA),纤维组织面积和脂肪组织面积。将所有案例分为动脉狭窄组和正常对照组组,观察房室结动脉PA/LA值及房室结纤维及脂肪含量的改变。结果狭窄组房室结动脉PA/LA值在21～40岁最大,40岁以下两组房室结脂肪含量和总间质含量差异有统计学意义。结论房室结动脉狭窄与房室结间质含量增多有一定关系。     

Mahaim纤维致猝死5例

寻找心源性猝死者的病理形态学诊断依据。采用本组建立的心传导系统检查法 ,对 16 5例无心外器官疾病猝死者的心脏 ,作心传导系统的组织学检查。发现 5例存在心传导系统Mahaim纤维 ,全部均为束室束型。本组Ma haim纤维的形态学与房室束 (HB)或左束支 (LBB)相似 ,胞体横径在 10～ 35 μm左右 ,胞浆丰富 ,色淡红染 ;来自HB的纤维胞体呈细条状 ,核居中 ;来源于LBB的则按其始发点不同自上而下逐渐变大 ,纵切细胞未见分叉 ,但部分细胞周围见有一薄层结缔组织包围。分析结果表明 ,Mahaim纤维是可致猝死的房室传导旁路。     

青年人CCS脂肪超前变化致猝死

为研究心传导系统（CCS）与猝死的相互关系，对120例心性猝死者CCS作常规检查，光镜下作半定量计算其脂肪含量。结果发现：9例经一般常规尸检未找到任何致死原因的青年人（30岁以下），其房室结（AVN）与房室束（HB）的脂肪组织含量为70％，比同龄人明显增多，致使结、束肌细胞被脂肪分割中断或压迫萎缩。结内外细胞连接不足或缺失是构成心电不稳的病理基础。此外本文尚对其脂肪浸润的病因发病，猝死机理作了探讨。     

心脏神经病

目的 研究心源性猝死的病理形态学。方法 用本组建立的CCS检查法对179例心源性猝死者作常规CCS组织学检查。结果 发现8例心脏神经或神经节内有出血、炎症或肿瘤浸润,伴神经组织水肿、变性、坏死,而其他病变不足以解释猝死。结论 一切原发或继发性心脏神经病均可致猝死。     

房室传导系统发育异常猝死的病理学研究

本文报告了三名男性青年人房室结和／或房室束、束支发育异常，在情绪激动和／或用力情况下突然无声息倒地死亡。经病理组织学研究，发现有胎儿型房室结、心传导系统附加束存在和房室结畸形等发育异常改变。本文对其病理组织学特征、猝死机理和诱因进行了讨论。     

一种简便的心脏传导系统检查法

<正> 心脏传导系统包括窦房结、房室结、房室束(His 束)、左右束支及其末稍等部分。其中窦房结和房室结是起搏的主要成分。猝死常与窦房结、房室结、房室束和束支结构异常或病变有关,尤以窦房结和房室结更为重要。半个世纪以来,国内外检查心传导系统的传统方法,主要是与其长轴方向垂直切取若干块组织,作连续切片,每例需检查数百甚至     

心脏传导系统的增龄性变化

心脏传导系统（CCS）包括窦房结（SAN）、房室结（AVN）、房室束（又称希氏束，HB）、左右束支（LBB，RBB）及其终末纤维网，其功能是把心脏搏动的冲动传导到整个心脏，以协调心脏的节律性收缩．近年来，CCS病变与猝死的关系引起重视，已有研究表明，一些猝死与CCS的病变有关。但在实际应用中，必须将CCS增龄变化同其病变区分开来，以免误将其正常增龄变化视为病变，导致错误的结论．1SAN的年龄变化在光镜水平，Lev[1]首先对53例4个月胎儿至90岁老人的SAN进行了分年龄组观察；Davies[2]对50岁以下和75岁以上两组各50例的SAN…     

300例心源性猝死案例的法医学鉴定分析

目的探讨心源性猝死案例的病因、诱发因素及法医病理学特点,以期为心源性猝死案件的法医病理诊断提供参考。方法收集法医病理检案中的心源性猝死案例,对其年龄、性别、死亡时间、死因、诱因及场所等流行病学特点进行回顾分析。结果 300例心源性猝死案例中男性多于女性,18~45岁发病最多;病因包括冠心病(129例),心肌病(78例),心肌炎(36例)等;应激为SCD最常见的诱发因素(157例)。结论 1应激和冠心病是心源性猝死的重要危险因素。2心源性猝死的法医学鉴定除了要进行系统的尸检及病理学检查外,还要对死者的相关资料如:基础疾病、诱因、死亡时间、死亡经过等进行全面系统的分析以明确死因。     

压迫房室束的心脏纤维瘤

原发性心纤维瘤极为少见，国外报告35例［1，2］，国内手术后确诊3例［3］。但发生在室间隔顶部、压迫房室束（以下简称HB）的纤维瘤国内未见报告，现将所遇见的3例报告如下。材料与方法材料来自1989年1月至1995年6月日常尸检案例，常规检查714例心传导系统（以下简称CCS），发现3例心纤维瘤。采用本组建立的CCS检查法“’，每例共取30片，每片厚SPm，HE、弹力纤维和Masson三色染色，光镜观察，肿瘤体积用显微测微器测量其最大切面。结果例1女，SO岁，既往健康。独睡，睡前无不适，早晨被家人发现已死二。尸检心重42Og（体重70kg），…     

Histopathological findings of cardiac conduction system of 150 Finns

One hundred and fifty heart specimens were collected from the cases submitted for autopsy in the Department of Forensic Medicine in the University of Turku in March-May 1995 and May-July 1996, respectively. The cardiac conduction system (CCS) of these hearts were examined in order to find out the histopathological changes in the CCS of Finnish persons and their forensic pathological significance. There were 94 males and 56 females. Almost all age groups were included. The results revealed that in most of the persons the fibrous tissue and fatty tissue in the CCS increased with aging. In about half of the persons, there was deposition of calcium in the central fibrous body, pars membranacea, and the top of the musculature in the interventricular septum. In seven cases, the atrioventricular node (AVN), His bundle (HB) or bundle branches (RBB, LBB) were compressed by the calcium deposition. Hemorrhage, inflammation, amyloidosis, tumor, fatty infiltration and developmental malformations were observed in 31 cases. Twenty-eight cases died of myocardial infarct, among them, no involvement of the CCS could be observed. The authors concluded that routine examination of the CCS is helpful for revealing diseases of the CCS and improving the quality of forensic pathological diagnosis.     

Sudden Death Due to Infiltration of Left Bundle Branches by Interventricular Septal Cardiac Fibroma

Cardiac fibromas are benign conditions; however, their location and size may cause ventricular arrhythmias and sudden cardiac death. We report a case of a 68‐year‐old female who died suddenly. Postmortem investigation detected a huge cardiac fibroma in the pars muscularis of the interventricular septum, occupying almost the entire muscular septum, and restricting the volume of left ventricular chamber. Histological examination revealed numerous foci of calcification in the alternating complex interlacing or strictly parallel collagenous fiber mass. Tumor mass was mainly demarcated, but in some places, fibrous infiltration of surrounding working cardiac muscle was found. We present a case when direct tumor involvement in the descending left bundle branches was evidenced. Mainly, the branches of septal fascicle were disrupted, entrapped, and degenerated by the tumor mass. This case report emphasizes that postmortem histological examination of conduction system in all sudden cardiac death cases may substantially improve the accuracy of postmortem diagnosis.     

心肌炎侵及心传导系统病理学观察

本研究采用已建立的人体心脏传导系统简易取材法,对6例心肌炎的案例进行了传导组织的病理学观察,结果发现6例心肌炎患者CCS均有明显炎症,尤以SAN、AVN病变为主;推测CCS炎症可能为心肌炎患者猝死的主要原因。因此,本文提出对怀疑心性猝死案例应作常规传导系统检查。     

婴幼儿猝死综合征心传导系统的免疫组化研究

作者应用ＰＧＰ９．５与抗Ｓ１００抗体和高压消毒蒸锅抗原复活技术对４例婴幼儿猝死综合征（ＳＩＤＳ）和３例非心源性死亡对照婴儿心传导系统的神经组织总量进行免疫组化研究。结果：在正常婴儿心传导系统，ＰＧＰ９．５与Ｓ１００阳性的神经纤维里不均匀分布，以窦房结最多，房室结次之，希氏束最少；４例ＳＩＤＳ心传导系统的神经组织分布同对照组无明显差异。     

Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

Age-related variation in the interstitial tissues of the cardiac conduction system; and autopsy study of 230 Han Chinese

The amount of fatty and fibrous tissues in 230 Han Chinese who died of noncardio-vascular diseases has been studied by a semi-quantitative method and analysed by chi-square test. The results have shown some consistency. Generally, in the sino-atrial node (SAN), fibrosis and fatty influtratin appear only after 40 years of age and increase one grade with every 20 years. The atrio-ventricular node (AVN) showed fatty change after 30 years of age and fibrosis appeared after 60. In the His bundle (HB), fatty infiltration and fibrosis appear after 40 years. The left bundle branch (LBB) showed similar changes. The appearance of fibrosis in the AVN seems to be later than that reported by Lev.