Floppy aortic valve presenting as sudden death

A previously healthy 34-year-old Dutch immigrant to Australia died unexpectedly in his sleep. At autopsy the only significant finding was a floppy aortic valve (FAV). Histologic, histochemical and electron microscopic studies corroborated the macroscopic diagnosis. Previously described associations of the FAV include the floppy mitral valve, Marfan's syndrome, aortic root dilatation and aortic cystic medial necrosis. None of these features were found in the present case which is the first recorded example of isolated FAV presenting as sudden death. The mechanism of death is obscure, and while it is presumed to be dysrhythmic, a detailed histological examination of the cardiac conducting system revealed no anatomic abnormality.     

Death by embolization of prosthetic aortic valve

This report describes a case in which a young woman died from embolization of her prosthetic aortic valve. The discussion includes the embolization's association with chronic intravenous narcotism, recurrent bacterial endocarditis, and acute cocaine toxicity.     

Sudden death in infancy due to bicuspid aortic valve

Symptoms of bicuspid aortic valve usually occur in the age group of 50-70 years, but rarely, it can also lead to sudden unexpected death in infancy and early childhood. The autopsy of a 2-month-old baby boy, found dead in his cot, revealed the heart weight as 25 g, and the macroscopic examination showed the circumference of the aortic valve consisting of two leaflets as 8 mm. The thickness of the left ventricle, right ventricle, and septum was measured as 8, 7, and 10 mm, respectively. Microscopically, the heart revealed hypertrophic changes of myocytes. Subendocardial areas displayed necrosis of myocytes, and severe and diffuse ischemic changes characterized by loss of myofibers and vacuolization. Interstitial pneumonia was identified in the lungs. Death occurred as a result of a congenital bicuspid aortic valve obstructing the left ventricular outflow tract complicated by lung infection. As there are only a few reported cases in infancy, and congenital bicuspid aortic valve can lead to sudden unexpected death, this case is presented to the forensic community.     

Mechanical failure of a mitral valve prosthesis: an unusual case of sudden unexpected death

Sudden unexpected death caused by the failure of a cardiac valve prosthesis is a rare occurrence. A 45-year-old female suddenly died three years following mitral valve replacement for rheumatic mitral stenosis. At autopsy, death was determined to be due to a metallic fatigue of the mitral valve prosthesis.     

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.     

Sudden death from left atrial pressure line wedging into cardiac valve prosthesis: pathologic findings and forensic significance

The case of a sudden death from late valve entrapment of a left atrial pressure monitoring line not removed postoperatively is considered from both biomechanical and pathological points of view because of its forensic significance in terms of malpractice liability.     

Sudden unexpected death due to papillary fibroma of the aortic valve. Report of a case and review of the literature

The case of the sudden unexpected death of a 21-year-old man due to embolization of segments of an aortic valve papillary fibroma to the left main and anterior descending coronary artery is presented. The literature regarding cardiac papillary fibroma is reviewed with particular reference to those cases associated with sudden death.     

Chronic cadmium intoxication caused by a dental prosthesis

We present a case of chronic cadmium intoxication caused by a gold dental prosthesis. The first symptoms of the disease appeared 2 years after insertion and gradually intensified over the next 3 years. Analysis of blood and urine samples, as well as parts of the prosthesis, revealed an excessive concentration of cadmium. The prosthesis was removed and the concentration of cadmium gradually returned to normal, with an amelioration of symptoms. This case illustrates the importance of investigating the possibility of intoxication with a heavy metal when symptoms of chronic illness accompany the presence of a prosthesis.     

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.     

Mandibular fracture following stab injury with a knife

Stab injuries of the face accompanied by fractures of the jaws are rare. The report deals with the case of a young man, who suffered a penetrating stab injury to the cheek and fracture of the mandible in an assault. The forensic questions to be answered were if the findings were compatible with a stab and subsequent fracture, if one of the confiscated instruments could have been the causative weapon and if the injury had to be assessed as life-threatening. Both the soft and the hard tissue injury confirmed the assumption that they were caused by a stab. It was not possible, however, to assign the injury to a specific knife from the submitted exhibits on the basis of the clinical findings. In the discussion the serious nature of stab injuries in the facial region is emphasized.     

Death related to aortic coarctation in a young female during sexual intercourse

Coarctation of the aorta (CA) is diagnosed mainly in pediatric patients, and therapy is conservative if asymptomatic, but surgical treatment is required if advanced arterial hypertension is present. Moderate to severe forms contraindicate any type of physical activity requiring cardiac effort. Here, we describe the first documented death of an apparently healthy 35-year-old woman because of cardiac tamponade by rupture of an aortic aneurysm, possibly related to congenital CA, prolonged use of oxymetazoline hydrochloride, and physical and/or emotional stress during sexual activity. Our patient was asymptomatic for classical CA symptoms. The patient's breathing difficulties likely in hindsight were due not so much to nasal congestion, but rather to an ineffective oxygenation of the blood from the abnormal heart. In an attempt to treat the "nasal disease," the patient ingested chronic and excessive doses of decongestants, aggravating her fatal disease. The danger of inhaling large doses of nasal decongestants without an appropriate medical indication is highlighted here.     

Fatal retropleural hematoma from a ruptured abdominal aortic pseudo-aneurysm

This paper has reported a case of sudden unexpected death in a 19-year-old man, shot in the abdomen, who was surgically treated and discharged. He died of massive left retropleural hematoma from a spontaneous rupture of a traumatic pseudo-aneurysm of the abdominal aorta. Diagnosis of the retropleural hemorrhage and the aortic pseudo-aneurysm was possible, though not made antemortem, through chest X-rays and ultrasound studies of the abdomen correlated with the patient's symptoms. Early radiologic signs of the hematoma consisted of obliteration of the aortic silhouette on the anteroposterior view and the left primary sulcus on the lateral film by a convex expanding homogenous density whose medial border blended imperceptibly with the mediastinal shadow. On ultrasound study the pseudo-aneurysm appears as semilucent midline shadow anterior to the vertebral column and related to the aorta, giving the latter an appearance of increased diameter.     

Sudden death in mitral valve prolapse

Four cases of sudden death in young females with clinical and pathologic features of mitral valve prolapse are discussed. The approach to postmortem examination of the mitral valve is reviewed and various risk factors are stressed. Because of the sudden nature of these deaths, this entity is more commonly seen in medical examiner's populations than hospital autopsies. A practical approach to the investigation of such cases is given.     

Unusual basal skull fracture in a vehicle equipped with an air bag

A woman who was the lap/shoulder belt-restrained driver of a car equipped with a full-size air bag was involved in an oblique frontal collision with a tractor-trailer combination. She was extremely out of position, i.e., witnessed to be slumped over the steering wheel before impact. This preimpact positioning led to fatal injuries resulting from the inflating air bag. Postmortem examination showed an unusual partial ring fracture of the base of the skull, which to the authors' knowledge has not previously been reported.     

Punched with a fist: the etiology of a fatal depressed cranial fracture

We report a case in which a 33-year-old man was discovered unconscious following a fistfight with another man. Emergency neurosurgical efforts to repair a depressed temporoparietal skull fracture and associated brain injuries were unsuccessful. The forensic anthropologist and pathologist worked in tandem to sort out a complex combination of cranial evidence, including healed antemortem trauma, perimortem blunt force trauma, remote and recent neurosurgical intervention, and the craniotomy cut performed at autopsy. The victim had suffered head injuries and a right temporoparietal craniotomy ten years prior to death. The perimortem cranial fractures were centrally located within a surgically repaired roundel of bone involving portions of the right temporal and parietal bones. Reportedly, the victim was punched on the right side of his head as he was lying on the ground with the left side of his head against an asphalt surface. A primary question in the case was whether a blow with a fist could have produced the observed cranial injuries. To adequately answer that question, known data on the minimum amount of force required to fracture the temporoparietal region were compared to data on the amount of force generated by a blow with a fist. A biomechanics expert demonstrated that a single blow with a fist to the rigidly supported head of the victim could generate the required force to produce the observed fractures. The previous medical condition possibly predisposed the victim to the cranial fractures and contributed to the depressed nature of the fractures. Although depressed cranial fractures do not typically result from a blow with a fist, it was determined in this case that the fracture pattern was consistent with a punch to the head.     

Marfan syndrome presenting as aortic rupture in a young athlete: sudden unexpected death?

A 20-year-old man had a spontaneous rupture of the ascending aorta while exercising. The diagnosis of Marfan syndrome, established by the gross and microscopic autopsy findings, was further supported by review of the autopsy report of the father, who had died at age 26 of a nearly identical aortic rupture. To avoid occurrences such as the above, the responsibility of the forensic pathologist should extend beyond the autopsy to appropriate counseling of families in instances where medically treatable hereditary conditions may be present in the survivors.     

Fatal pulmonary haemorrhage from a perforated and possibly iatrogenic thoracic aortic aneurysm

A 56-year-old man, with Noonan's syndrome, underwent surgical correction of an aortic co-arctation almost two decades before his sudden and unexpected demise. The immediate cause of death was massive pulmonary haemorrhage, which was preceded by recurrent mild haemoptysis that was attributed to pneumonia, clinically. Autopsy revealed the presence of a saccular thoracic aortic aneurysm, arising from the apparently weakened anastomosis left by the previous operation. The aneurysm had eroded into the apical segment of the left lung, where it perforated with consequent severe, acute pulmonary haemorrhage. It was observed that the anastomotic line traversed the aneurysmal wall, with the resultant formation of a true aneurysm, rather than merely a pseudo-aneurysm. It is postulated that this finding of an iatrogenic true aneurysm represents a rare, delayed complication of aortic surgery.