Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature

Non‐atherosclerotic spontaneous coronary artery dissection (NA‐SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA‐SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow‐up) to invasive angiographic procedures. Rarely, NA‐SCAD has recurred in another coronary artery, ranging hours to years later. We report NA‐SCAD of the right coronary artery (RCA) in a 30‐year old, 3‐month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA‐SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA‐SCAD recurrence in a subsequent pregnancy.     

Acute Aortic Dissection Diagnosed after Embalming: Macroscopic and Microscopic Findings

A 58‐year‐old man died suddenly in Madagascar and poisoning was suspected. The body was embalmed after death and the general state of preservation was good. We found a major aortic dissection with a large false lumen from the aortic root to the common iliac arteries and a hemopericardium with formalinized blood clot. The intimal tear was on the ascending aorta, and an intramural hemorrhage was noted at the right coronary artery, attesting to a retrograde dissection. Microscopic studies confirmed aortic dissection with extensive intramural hemorrhage and also confirmed the retrograde dissection to the right coronary artery with a reduction of 90% of the true lumen. Classically, aortic dissection occurs in individuals with hypertension and individuals with genetic disorders of collagen formation. The diagnosis is often first established at the postmortem examination. Aortic dissection is therefore dealt with largely in necropsy studies. The usual cause of death is rupture into the pericardial sac. One case of bloodless dissection has been reported but the sudden death was explained by acute myocardial ischemia secondary to dissection of the left coronary artery. In our case, we found major hemopericardium and also intramural hemorrhage at the right coronary artery. We were able to make the diagnosis of aortic dissection and exclude the suspicion of homicide 15 days after death and after embalming.     

Acute Fatal Coronary Artery Dissection Following Exercise‐related Blunt Chest Trauma

Coronary artery injury such as acute coronary dissection is an uncommon and potentially life‐threatening complication after blunt chest trauma. The authors report an unusual autopsy case of a 43‐year‐old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma.     

Spontaneous dissection of the distal obtuse marginal coronary artery: a rare cause of sudden death

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction and sudden death. It typically, but not always, occurs in healthy postpartum women without traditional risk factors for atherosclerosis. Moreover, the site of dissection usually involves the proximal, major coronary arteries: left main coronary artery and/or the left anterior descending artery, and in men, more often the right coronary artery. We report a case of sudden death caused by dissection of the obtuse marginal branch of the left circumflex artery, in a 49-year-old man, a very rare site of fatal coronary dissection.     

"Spontaneous" coronary artery dissection. The challenge of detection, the enigma of cause

Sudden death secondary to acute dissection of a coronary artery is a rare, but increasingly recognized, cause of sudden, unexpected death in apparently healthy persons. It has been reported more frequently in women and has been associated with sudden death during the puerperium. It has also been reported that these involved coronary vessels contain increased numbers of eosinophils and often show areas of cystic medial necrosis. In this article, we report a case of sudden death in a 47-year-old white woman due to dissection of the distal segment of her left anterior descending coronary artery. There was marked involvement of the coronary arterial walls with cystic degeneration of the media with accumulation of glycosaminoglycans as demonstrated by Alcian blue staining. There was no eosinophilic infiltrate within the arterial walls. This case is unusual in that this woman's mother and brother both have had aneurysms, which stresses the importance of not only searching carefully for these lesions, but also of obtaining family history in such cases.     

Aortic Dissection and Sudden Unexpected Deaths: A Retrospective Study of 31 Forensic Autopsy Cases

Acute aortic dissection (AAD) is the most common cause of sudden unexpected death related to aortic diseases. A retrospective study of 31 sudden unexpected deaths caused by AAD was conducted at Xi'an Jiaotong University Forensic Center from 2001 to 2012. We summarized the forensic characteristics of AAD and assessed the clinically diagnostic accuracy of AAD. The characteristics of sudden unexpected death due to AAD were male predominant (male: female = 6.7:1), relatively young with the mean age of 44, and predominance of type A dissection (77.4%). Cardiac tamponade was the most frequent cause of sudden death (87.1%). Of the 31 cases, 26 (83.9%) patients were not recognized clinically and were misdiagnosed with acute myocardial infarction, coronary artery disease, cholecystitis, acute gastroenteritis, renal/urinary lithiasis, or acute pancreatitis. In summary, AAD can be difficult to recognize, diagnosis is therefore sometimes delayed or missed. The medicolegal death investigation can help physicians have a better understanding of AAD.     

Is right coronary artery hypoplasia and sudden death an underdiagnosed association?

Determining whether hypoplasia of a coronary artery has caused or contributed to death is often complicated by an absence of histologic evidence of myocardial ischemia in the area of the heart supplied by the affected artery and also by the lack of data for assessing coronary artery size at autopsy. A 45-year-old woman is reported who collapsed and died and who was found at autopsy to have a dominant, small-caliber, right coronary artery, with acute and chronic ischemic changes in the posterior interventricular septum supplied by the diminutive vessel. This case provides evidence that small-caliber coronary arteries may be associated with a lethal outcome. Given the difficulties that may occur in determining whether there is a causal link between small coronary artery caliber and death, it is possible that this may be an underdiagnosed cause of sudden cardiac death, rather than a coincidental finding of minimal significance.     

A study of various morphologic variables and troponin I in pericardial fluid as possible discriminators of sudden cardiac death

Pathologists frequently examine victims of sudden cardiac death. In some cases, a firm diagnosis of cardiac-related death can be made based on conclusive gross and histologic findings. In many other cases, we find evidence supportive of, but not diagnostic of, cardiac death (e.g., atherosclerotic coronary artery disease, cardiomegaly, myocardial scarring). A final cohort consists of cases of sudden death with minimal to mild cardiac disease, no other significant pathology, and negative toxicologic studies. This prospective study compared 38 cardiac-related deaths with 52 control cases with respect to concentrations of pericardial cardiac troponin I (cTnI), heart weight, evidence of old and/or recent myocardial injury, and presence of significant coronary artery disease. The influence of documented chest trauma and/or perimortem cardiopulmonary resuscitation (CPR) on levels of cTnI was also analyzed. Even though median cTnI levels were significantly higher in cardiac deaths than in controls (p = .003), cTnI was not found to be a significant predictor of cardiac deaths, as determined by discriminant analysis (p = .52). Heart weight >500 g, evidence of old and recent myocardial injury, and significant coronary artery disease were seen statistically more often in cardiac deaths than in controls (p < or = .005 in each case), and median age was significantly higher in cardiac deaths than in controls (p = .001). Based on a stepwise logistic regression model, significant coronary artery disease, old and recent myocardial injury, and heart weight >500 g were found to contribute significantly to the prediction of cardiac death. Finally, neither chest injury nor CPR significantly affected concentrations of cTnI in pericardial fluid. These data confirm that the presence of acute and remote myocardial injury, significant coronary artery disease, and cardiomegaly (heart weight >500 g) strongly supports the diagnosis of a cardiac-related death. In contrast to a recently published report, we do not find that elevated concentrations of cTnI in pericardial fluid are strong indicators of cardiac-related deaths using our methodology.     

Occlusion of left and right coronary arteries and coronary sinus following blunt chest trauma

Blunt chest trauma from rapid automobile airbag deployment causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a 37-year-old man who developed extensive anterior and inferior myocardial infarction because of occlusion of both left anterior and right coronary arteries following blunt injury to the chest in a car accident. The patient was scheduled for emergency coronary angiography but left and right coronary ostia were not cannulated because of thrombus formation probably. The patient died, and the autopsy revealed external compression by epicardial hematomas involving separately left and right coronary arteries and the coronary sinus without signs of coronary and/or aortic dissection. To our knowledge, this is the first case presenting occlusion of both coronary arteries secondary to blunt chest trauma causing acute myocardial infarction in a young man without signs of prior coronary artery disease.     

Fatal postpartum coronary artery dissection. A light- and electron-microscope study

A case report of fatal spontaneous dissection of the distal left circumflex coronary artery in a 37-year-old postpartum female is presented. Samples of arterial wall from this patient and from six other postpartum females who died of unrelated causes were examined by light (LM), scanning electron (SEM), and transmission electron (TEM) microscopy. Morphological changes to explain the recognized predisposition of this cohort to coronary artery dissection were sought. The origin of the dissection was demonstrated by serial LM sections to be in midmedia with no intimal extension. The predominant plane of dissection was the junction of media and adventitia. Sarcolemmal blebbing and accumulation of amorphous intercellular material were demonstrated at the dissection site by SEM but were not seen elsewhere in the affected heart or in any of the six control hearts. These changes could not be distinguished by TEM from prolonged ischemic injury. There was no accumulation of eosinophilic leukocytes in the vessel wall or adventitia, and adventitial mast cells were not consistently more frequent than in the controls. No increase of stainable intramural mucopolysaccharides was seen in the fatal case. The results indicated no generalized arterial change in postpartum coronary arteries to account for the increased frequency of dissection. A focal degenerative process remains the most likely possibility.     

Sudden Death Due to Coronary Arteritis

We report the case of a middle‐aged man, without medical history, who suddenly died at his workplace. The autopsy highlighted a pathological heart macroscopically, with multiple small white areas on the left myocardium. Coronary dissection revealed a pseudotumoural fibromyxoid aspect within the anterior interventricular artery (AIVA) and the left main coronary trunk, including reduction in their diameter with tight stenosis. Microscopic examination of these arteries showed fibroinflammatory wall destruction. In the left myocardium, there were multiple focal ischemic areas at different stages of recovery. Our case is an illustration of primary ischemic heart disease due to coronary arteritis, with a pseudotumoural presentation, which was revealed by sudden death. We discuss the cause of death and the etiological diagnosis preceding coronary arteritis.     

Coronary thrombus and peracute myocardial infarction visualized by unenhanced postmortem MRI prior to autopsy

Sudden cardiac deaths are common within the community. They also constitute a substantial part of daily pathologic and forensic case work. However, macroscopic myocardial findings indicating acute ischemia are often absent. Then, diagnosis is based on coronary status in combination with indirect signs of acute cardiac failure. We present a case of sudden cardiac death where diagnosis was based on cardiac postmortem magnetic resonance imaging (pmMRI) findings already prior to autopsy: the heart's anterior basal ventricular septum showed hypointensities in T2-weighted images that raised suspicion of peracute ischemia. The lumen of the left anterior descending artery (LAD) exhibited a lack of otherwise discernible postmortem sedimentation of cellular blood components. Instead of a sharp border between serum and erythrocytes a homogeneous signal was seen within the narrowed lumen of the beginning LAD over a length of 1cm. Based on this, a thrombotic occlusion was assumed. Subsequent autopsy confirmed peracute septal myocardial ischemia secondary to a thrombotic occlusion of the LAD as concluded from the pmMRI.     

Impact of Myocardial Infarction and Abnormalities of Cardiac Conduction System on Sudden Cardiac DeathCSCD

Sudden cardiac death (SCD), most commonly seen in coronary heart disease, is a kind of sudden death caused by series of cardiac parameters, which usually combines with myocardial infarction. However, some SCDs (including early myocardial infarction) happen suddenly and cause death in a very short time. In these circumstances, typical morphological changes are lack in macroscopic or microscopic fields, which make such SCDs become the emphasis and difficulty in the present research. SCD caused by myocardial infarction and abnormalities of cardiac conduction system (CCS) is related to atherosclerosis of coronary artery closely. This paper reviews cardiac dysfunction caused by myocardial infarction and diseases of CCS from morphology and molecular biology, and explores potential relationship between them. This paper aims to provide clues to the mechanism of myocardial infarction related sudden death and possible assistance for forensic diagnosis of SCD. © 2017 by the Editorial Department of Journal of Forensic Medicine.     

Sudden death due to dissecting pulmonary artery aneurysm: a case report and review of the literature

Pulmonary artery aneurysm and pulmonary artery dissection are rare antemortem diagnoses, most often associated with sudden death. These pathologic entities are strongly associated with chronic pulmonary hypertension due to structural cardiac defects, either congenital or acquired. We report the case of a 49-year-old woman who died suddenly due to dissection and rupture of a large pulmonary trunk aneurysm, with subsequent cardiac tamponade. Key historical and physical findings are described. Additionally, we present a discussion of the incidence, clinical presentation, pathogenesis, and pathologic diagnostic features of pulmonary artery dissection.     

急性心肌缺血早期血管内皮生长因子的免疫组织化学实验

对大鼠急性心肌缺血早期的不同时间、心脏不同部位的血管内皮生长因子（VEGF）的表达，运用免疫组织化学方法进行了研究。结果发现：缺血30min后在缺血心肌局部开始出现VEGF阳性表达，而缺血边缘区域和正常区域心肌在缺血1h后也开始出现VEGF阳性表达，并随着缺血时间的延长，VEGF的表达强度也越来越强。对照组未发现有阳性表达结果.表明运用免疫组化方法检测心肌缺血后心肌局部VEGF的表达，可望作为因心肌缺血导致心脏性猝死案例的诊断标准之一。     

Left Ventricular Aneurysm: Sudden Unexpected Deaths in a 29‐Year‐Old Man

Left ventricular aneurysm (LVA) is an abnormal dilated heart structure, either congenital or acquired. LVA is a rare cardiac condition with no symptoms in most cases, thus occasionally diagnosed during investigations of other diseases. Its association with certain cardiac complications and sudden cardiac deaths has been reported. However, its role as a cause of sudden unexpected death is rare. The author reported a sudden cardiac death in a 29‐year‐old man with LVA. Without a significant coronary artery disease and known etiologies of LVA, such an abnormal heart structure in the present case was considered congenital LVA. As no other possible mechanisms of death could be identified other than LVA with its associated pathologic lesions, mural thrombi, and dilated cardiomegaly, his death was attributable to fatal cardiac arrhythmia (most commonly ventricular tachycardia) secondary to LVA.     

Morphometrische Untersuchungen bei stenosierender Koronarsklerose und ihre Bedeutung für die Bewertung konkurrierender Todesursachen

Coronary sclerosis is generally supposed to be the most important factor for coronary thrombosis, myocardial infarction and coronary heart death. Stenosing coronary sclerosis may be postmortally documented by angiography and morphometry. It is possible to obtain sufficient morphological data to suggest acute cardiac insufficiency, if the maximum grade of stenoses as a functional parameter and the heart weight are regarded in addition to the quantitative results of the three main branches of the coronary arteries (lumen and intima areas).Generally the cardiac results of autopsy are used individually and subjectively for the explanation of the cause of death. The conclusiveness of these results of autopsy depends on the circumstances of death and the existence of further pathological findings. Competing causes of death may exist in the form of illnesses, injuries, alcoholic and drug effects, physical strain and emotional stress or medical provisions. The quantitative valuation of the cardiac findings with a critical limit for an acute coronary death permits a more exact interpretation of such competing causes of death. This method of examination may also reveal an unpresumed competing cause of death, for example an intoxication. This was demonstrated by four autopsy cases.     

Unexpected sudden death of a 12-year-old male with congenital single coronary artery

A rare autopsy case of a 12-year-old male with a single coronary artery is reported in which he suddenly and unexpectedly died after a brief period of physical and mental excitation. The single coronary artery originated from the left aortic sinus, then branched out the left circumflex artery and afterwards descended as the left anterior descending artery, while the right coronary artery originated almost at a right angle from the left anterior descending artery. The entire heart as well as the cardiac conduction system depended exclusively on the single coronary artery for oxygenated blood supply, and the unbalanced blood distribution on his exertion probably led to sudden cardiac death. Moreover, in this case, both the deceased's mother (at the age of 20 years) and grandmother on the mother's side died suddenly, thus suggesting a possibility of maternal transmission of this congenital anomaly in his family.     

Intracoronary Thrombus Formation Following Carbon Monoxide Poisoning

Thromboembolic events in the context of carbon monoxide (CO) exposure have been well described in the literature. Six cases of clinically significant coronary thrombosis following CO exposure were previously reported. However, factors affecting the development of coronary thrombus in CO exposure are poorly understood, and the significance of this finding in a forensic context is not clear. This article discusses a case of coronary thrombosis found at autopsy following a death in which CO poisoning was suspected. A 67‐year‐old man was found dead in his garage with four vehicles with their ignition in the “on” position and their tanks empty. At autopsy, severe coronary atherosclerosis and an acute nonocclusive coronary thrombus were found. Given the dissimilarities among cases and the presence of CO exposure, it was suggested that the coronary artery thrombosis is likely due to the inherent prothrombotic mechanism of CO, the only common denominator in all the cases.     

Cardiovascular Conditions and the Evaluation of the Heart in Pregnancy‐Associated Autopsies

Abstract: Pregnancy‐associated death is defined as the death of a woman from any cause during pregnancy or in the year after delivery. This review concentrates on cardiac conditions that may result in pregnancy‐associated death including, but not limited to, acute myocardial infarction, endocarditis, peripartum cardiomyopathy, and prolonged QT syndrome. Lethal vascular conditions may also occur involving arterial dissection and thromboembolism, on occasion exacerbated by hypercoagulability, and altered hormonal and physiologic states. The autopsy evaluation of these patients includes a careful assessment of the medical history particularly for prior pregnancy‐related conditions, fetal loss, and episodes of unexplained collapse. A family history of sudden death at an early age may be significant. At autopsy, evaluation for underlying syndromes such as Marfan, or evidence of intravenous narcotism should be undertaken. Autopsy examination involves careful dissection of the heart and vessels with consideration of conduction tract studies and possible genetic evaluation for prolonged QT syndrome.