SUDDEN CARDIOVASCULAR DEATH

Lina Paola AvellaGina CastellanosRaul CastillaFabian GalarzaNatalli RodriguezJulieth SantosXimena Tovar

Contents

Introduction Evaluation on the clinical history Sudden death First article

Cases Discussion

Second article Abstract Discussion

Contents

Third article Abstract Clinical stages of ARCV Clinical Diagnostic Criteria of ARCV

Morphological findings at forensic autopsy Checklist

Histological examination of the heart Examination of the cardiac conduction system Laboratory test Conclusion

Video

Video

Introduction

Natural deaths > Unnatural deaths. Sudden unexpected deaths

Cardiovascular diseases: 51.8% > 80%: Coronary atherosclerosis.

Introduction

This requires:

Pathologists: Complex task.

Synthesis of scene

investigation

Medical history

Autopsy findings

Auxiliary studies

Formulating the report

Evaluation on the clinical history The first step Six groups of information*

* Association for European Cardiovascular Pathology

Basic personal

data

Circumstances of death

Medical history

Medication use

Family history of cardiac

diseases

Previous test results

Sudden DeathUnexpected

death

Natural Unexpected

death

Natural unexpected

cardiovascular death

*Neural arrhythmia *Mechanical

infarct congestive

failure

“Commotio cordis” Sexual activity

Arrhytmogenic right

ventricular cardiomyopaht

y

Natural unexpected

nervous death*Neural reflex,

seizure*Mechanical herniation

infarct

Natural unexpected respiratory

death*Neural apnea*Mechanical embolism asphyxia

Un-natural death

Suicide Accident Criminal

Cases

Discussion

Abstract

Discussion

Arrhythmogenic right ventricular cardiomyopathy (ARCV)

Young Adults

Cause of sudden death in this age group

Without prior history

Clinical Stages of ARCV

IConcealed

phase

• Whitout symptoms• Minor electrical disturbances• Impending risk of sudden death

IIOvert phase

• Arrhythmic disorders• Ventricular tachycardia

IIIAdvanced stage

•Myocardial loss•Dilated cardiomyopathy

Clinical Diagnostic Criteria of ARCV

Pathology Clinical History Tissue characterization of wall

Depolarization abnormalities Family historyGlobal/regional dysfunctionStructural alterationsRepolarization abnormalitiesarrhythmias

Common morphological findings at forensic autopsy Atheroesclerotic Narrowing of

coronary arteries

Myocardal Scar Dissection of coronary Arteries Examinate lungs

Proximal left Anterior desending A.

Left circumflex coronary A.

Standard prodedure for examination of heart (checklist) Pericardium and pericardial cavity. Anatomy of the great arteries

Valves and trunk

Pulmonary

Aorta

Standard prodedure for examination of heart (checklist) Pulmonary veins, superior and

inferior veane cavae.

Open Incision

Left Atria

Inferior V. cava to apex of the

appendage

Pulmonary veins to atrial

appendage

Right Atria

Standard prodedure for examination of heart (checklist)

Sinus Node

Esta pendiente una foto mas bonita en donde se mire auricaulas , septum interauricular, y valvul mitrla y tricuspidea se r eciben sugerencias

Standard prodedure for examination of heart (checklist) Aorta and pulmonary artery including

valves

Coronary Arteries

Size Shape Position NumberCourseDOMINANCE

Standard prodedure for examination of heart (checklist) Coronary Arteries

Make multiple cuts at 3mm intervals along epicardial

A.

Arteries again after fixation

Standard prodedure for examination of heart (checklist)

Ventricular DisectionStandard Incision through the blood Flow

Transv. Cut of heart at mid ventricular level and parallel slices 1 cm

Sectioning at inflow of heart throug left and right AV valves.

Foto pendiente

Anatomy heart, ischemic, congeital lesions

Morphology of walls and cavities

Small heart fetus rarely adults autopsy

Standard prodedure for examination of heart (checklist) Total Heart weight Wall thikness Heart Dimension

Standard histological examination of the heart Myocardium

Coronary Arteries

Right atria and vetricularLeft atria and ventricular

Ventricular septumMacroscopic abnormalities

Focal Lessions

Examination of the cardiac conduction system Some cases of apparent NUCD

without gross cardiac abnormality. Rare to find lesions at nodes Blood suply of Nodes before take

samples for histology studies. Sinus / Atrioventicular Nodal Artery ¼ Cranial Right atrial wall of terminal

groove: Sinus Node

Cardiac conduction system

Images of nodal and atrioventricular artery

Image of the ¼ right atrial wall

Cardiac conduction system

Triangle of Kock Anterior half of septal leaflet of

tricuspid valve for histology

Image of kock`s triangle and sample for histology

Cardiac conduction system

Electrophisiologic studies with reentry of miocardial conduction. Radiofrecuency Ablation

Lethat lesions: Narrowing of AV Node Artery

Fibromuscular Hiplerplasia

AV Node Tumors

Laboratory Test

Creatine phosphokinase and isoenzymes

Rised in deaths of cardiac disease Early MI without evidence on routine

histological examination Measurement in blood and

pericardial fluid Before macro-microscopic evidence

of MI Combined Morphological,

Histochemical and Biochemical methods

Toxicology

Depending circumstances surrounding the death and tox. data the manner can be accidental, natural or criminal

Even with findings, may have a substance triggered or caused the death?

Young- athlets: Doping or recreational drugs

Molecular Pathology

Almost 1/3 of cases have as cause of sudden death

Pathogenic mutation in long QT syndrome

Cathecolaminergic polymorphic ventricular tachycardia = associate genes

High Risk Groups

Medical conditions : History of MI or Isquemic Heart Disease, Hipertension, Aortic Stenosis.

Morbid Obesity: Dilated cardiomyopathy Severe coronary atherosclerosis Concentric left ventricular hipertrophy Young predispose by vigorous weight

training + anabolic steroids use to Myocardial injury or even SD

Conclusion

Any Question?

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