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: Case Report and Literature Review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction and sudden cardiac death. It occurs most commonly in otherwise healthy women during pregnancy or the postpartum period. The true incidence of SCAD is underestimated, as most cases are diagnosed at autopsy. The pathophysiology of SCAD is still not fully understood, and its management can be challenging. This report describes a 35‐year‐old pregnant female who presented with an acute antero‐lateral ST elevation secondary to spontaneous dissection of the left anterior descending artery and the circumflex artery. The diagnosis was established by coronary artery angiography. However, the patient died following cardiac tamponade. The examination of this case represented a starting point for the reviewing of the diagnosis, clinical course, and management of SCAD, and for the placing of this in context with the existing literature. This study highlights the importance of prompt diagnosis and subsequent lifesaving treatment.     

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.     

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.     

大鼠急性心肌梗死心肌ER表达的变化规律

目的探讨大鼠急性心肌梗死后非梗死区心肌雌激素受体(ER)的变化规律。方法选择雄性大鼠120只,分为正常组、手术组和假手术组,建立急性心肌梗死模型,在不同的时间点处死大鼠取心肌组织,常规HE染色,用免疫组化SP法和显微图像分析对ER表达的变化进行定量研究,用统计学方法进行处理,观察是否有统计学意义。结果急性心肌梗死后非梗死区ER的表达随着时间逐渐增多,手术后12h内增高不明显,24h开始增多明显,4～9d增多更为明显。结论急性心肌梗死后,非梗死区的心肌细胞可能通过增加ER的表达,发挥对心脏急性心肌缺血的保护作用。     

Therapy-related café coronary deaths: two case reports of rare asphyxial deaths in patients under supervised care

Café coronary deaths, as initially characterized, denote fatal occlusion of the upper airway by food substances. Such fatalities typically occur in individuals who either are clinically inebriated or have clinically significant neuromuscular dysfunction. Both conditions impair mastication and deglutition. The authors review the accidental deaths of two neurologically compromised patients under supervised care. Both subjects underwent complete medicolegal autopsy. In one case, ingestion of a prescribed emollient laxative precipitated death; in the other, death was attributable to aspiration of a contrast medium during a diagnostic radiographic procedure. These therapy-related deaths, which are regarded as a variation of the traditionally described café coronary fatalities summarized in the discussion, represent adverse events occurring during medical care. The adverse outcomes reviewed here are potentially avoidable and require special attentiveness by the clinicians directed to the particular condition of each patient. Such true aspiration-related deaths are confirmed on autopsy examination and are to be differentiated from the findings of agonal aspiration of gastric contents commonly encountered by the autopsy pathologist investigating deaths due to a great variety of natural and traumatic causes.     

Death related to coronary artery fistula after rupture of an aneurysm to the coronary sinus.

Large coronary fistulas are considered to cause myocardial ischemia due to diversion of the coronary blood flow. In this case the authors report the reverse effect--the spontaneous closure of a large fistulation between the left circumflex artery and the coronary sinus evoked angina pectoris in a middle aged man, who died several years later. Postmortem examination revealed a coronary aneurysm that had ruptured and dissected into the coronary sinus and finally thrombosed. The origin of the aneurysm could be congenital but perhaps also represents a healed stage of Kawasaki disease.     

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.     

Circumflex artery from the right coronary sinus: a not-so-benign anomaly

The origin of the circumflex coronary artery from the right sinus of Valsalva is generally considered a benign anomaly. Herein we report the sudden unexpected death of a 6-year-old boy who died after jumping into a swimming pool and whose only pathologic finding was this usually inconsequential coronary artery anomaly. A discussion of the pathophysiology of the disorder and a literature review are included. This is the youngest patient to die with this entity.     

Death following spontaneous recovery from cardiopulmonary arrest in a hospital mortuary: 'Lazarus phenomenon' in a case of alleged medical negligence

We report a possibly first forensic autopsy case of death following a spontaneous recovery from cardiopulmonary arrest (CPA) after clinical declaration of death: 'Lazarus phenomenon'. A 65-year-old male with congenital deafness and dumbness was found unconscious in his room at a public home. During pre-hospital and clinical resuscitation including defibrillation and medications for about 35 min, CPA persisted under electrocardiographic (ECG) monitoring and therefore, his death was pronounced. However, about 20 min later, a police officer who had been called for the postmortem investigation found the patient moving in the mortuary. The patient subsequently showed typical ECG signs and laboratory findings of early inferior wall myocardial infarction and died 4 days later. The forensic autopsy, due to alleged medical negligence, revealed myocardial infarction with thrombotic occlusion of the right coronary artery and secondary hypoxic brain damage. The present case and the related clinical literature suggest that, especially in cases of acute myocardial infarction in elderly patients, a careful observation to confirm death after discontinuation of resuscitation is recommended to provide appropriate medical care, irrespective of the quality or duration of advanced life supporting efforts.     

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.     

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.     

冠心病猝死冠状动脉粥样硬化斑块病理形态学观察

目的观察冠心病猝死(SCD)和对照组心冠状动脉(CA)粥样硬化斑块的差异,探讨其在SCD中的意义。方法从本教研室2001年~2003年尸检档案中挑选64例有严重CA粥样硬化病变的病例及心脏标本,分SCD组(36例)和对照组(28例冠心病非猝死者)。除常规检查心脏外,重点检查CA左主干(LM)、左前降支(LAD)、左旋支(LC)和右主支(RM)的开口、类型、走向及粥样硬化斑块情况。每支CA分近、中、远3段,检测每个斑块距开口的距离、狭窄程度、长度、数目和形状(分偏心、环形、偏心+环形三种)。用SPSS11.5统计软件进行统计分析。结果SCD组中CA粥样硬化病变4级21例,3级15例;对照组4级12例,3级16例。两组斑块病变的严重程度无显著性差异(P>0.05)。SCD组粥样斑块长(x-2.0365 cm)、以CA近段较多、与CA开口或分支处的距离近(x-0.7457 cm);对照组斑块短(x-1.4283 cm)、以中段多见,与CA开口或分叉处的距离远(x-2.1942 cm);两组斑块的长度和距开口的距离均有非常显著性差异(P<0.01)。两组间斑块的形状在LAD和RM有显著性差异(P<0.05),而LM和LC则无(P>0.05)。结论SCD与冠心病非猝死者的CA粥样硬化斑块在部位、长度、形状和距CA开口的距离存在差异,而狭窄程度无差异。这对SCD的病理诊断和法医学鉴定具有十分重要的意义。     

Kinking of a coronary artery as a rare complication in mitral valve replacement

We present the case of a 70-year old woman who had elective mitral and aortic valve surgery. She underwent surgery without complications for about 4h until 4 pm. Approx. 3h after surgery her condition deteriorated. 1500ml of blood were collected in the chest drainage until 11 pm. An emergency thoracotomy in the patient's bed showed a ventricular rupture. Death occurred around 11:30 pm. At autopsy, the implants of the biological mitral and aortic valves were found to be sewn tightly. There was no vascular injury and no unusual bleedings to the mediastinum. In the left ventricular wall, a rupture of 1cm and a surrounding fresh myocardial infarction area of 10cm×6cm was noted. Preparation of the coronary arteries showed moderate coronary atherossclerosis without stenosis or clots. The left circumflex coronary artery (LCX) showed a sharp, obviously stenosing kink which had been caused by the mitral valve surgery. Exsanguination due to ventricular rupture following myocardial infarction caused by implant-related "kinking" of a coronary artery, was found to be the cause of death.     

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.     

Poor results in attempting to demonstrate the cause of death by examination of the conduction system of the heart in cases of sudden death

A microscopic examination of the proximal part of the conduction system in the heart was undertaken in seven cases of sudden death due to coronary arteriosclerosis; the same technique was applied to 31 control cases. A few infiltrations of mononuclear cells were demonstrated in relation to the conduction system in cases of sudden death as well as in controls. In one case severe narrowing of the sinus node artery was found without particular arteriosclerosis of the coronary arteries.     

Cardiac rupture due to severe fatty infiltration in the right ventricular wall

An extremely rare case of sudden death caused by cardiac rupture due to severe fatty infiltration in the right ventricular myocardium is presented. The patient, a 74-year-old woman, had no history of chest trauma, hypertension, or pulmonary disease. The autopsy showed a small tear in the right ventricle and cardiac tamponade, but no coronary artery lesion. In the right ventricular myocardium, muscle fibers were definitely atrophic or absent, with massive fatty replacement. Fatty infiltration of the myocardium, if severe, can be a cause of serious cardiac dysfunction or, occasionally, sudden death.     

Fatal renal hemorrhage after extracorporeal shock wave lithotripsy

Renal hematoma is one of the most severe complications of extracorporeal shock wave lithotripsy (ESWL). ESWL is used in the noninvasive treatment of urinary calculosis. The shock waves can lead to capillary damage, renal parenchymal or subcapsular hemorrhage. We present a case with fatal complication and the result of the medico-legal evaluation. A 71-year-old woman was treated by ESWL, renal hematoma was detected during the clinical observation, and the patient died. The death occurred despite close clinical observation as a consequence of a rare complication of ESWL. The mechanism of death was hemorrhagic hypovolemic shock due to renal hemorrhage complications due to ESWL for treatment of renal calculi. This therapeutic complication is a known complication of appropriate treatment.     

Multivascular atheromatous coronary microembolism

We report an unusual case of coronary-multivascular, small coronary artery embolism by atheromatous elements originating in a plaque in the main right coronary artery of a 52-year-old man who died of acute thrombotic occlusion of the severely stenotic left anterior descending vessel. The embolized arteries showed the characteristic multiphasic inflammatory changes of different ages previously described in arteries occluded by this material. The myocardium supplied by the involved channels showed ischemic damage of varying ages. Both these observations indicate that the multiple emboli had been discharged at different times, rather than as a single shower. Finally, we make a plea for the use of the correct term "erosion" rather than "ulcer" for the lesion that is the source of the invasive obstructions.     

Papillary fibroelastoma of the aortic valve: a sudden death case of coronary embolism with myocardial infarction

Papillary fibroelastoma is a rare benign tumor, occasionally causing angina or sudden death. We report an autopsy case of an aortic valve papillary fibroelastoma with coronary artery embolism. The patient was a 68-year-old Japanese man who had collapsed suddenly in his house. He was a heavy drinker and had a history of liver disease but no notable cardiac event. The autopsy revealed extensive transmural infarction of the inferior wall of the left and right cardiac ventricles. The distal portion of the right coronary artery (segment 4, NYHA) was completely occluded by tumor emboli of the fibroelastoma. At the site of closure of the aortic non-coronary cusp, there was a typical papillary fibroelastoma, which was considered to have originated the coronary embolization.