MDCT in the diagnostic algorithm in patients with symptomatic atrial fibrillation

Atrial fibrillation(AF) is the most common supraventricular arrhythmia and a major cause of morbidity.Arrhythmogenic foci originating within the pulmonary veins(PVs) are an important cause of both paroxysmal and persistent AF.A variety of endovascular and surgical techniques have been used to electrically isolate the PV from the left atrium.Pulmonary venography for localization of the PV ostium can be difficult to perform during the ablation procedure.While the anatomy of the PV is patientspecific,non-invasive imaging techniques may provide useful diagnostic information prior to the intended intervention.In this context,multidetector computed tomography(MDCT) visualization of the left atrial and PV anatomy prior to left atrial ablation and PV isolation is becoming increasingly important.MDCT imaging provides pre-procedural information on the left atrial anatomy,including atrial size and venous attachments,and it may identify potential post-procedural complications,such as pulmonary vein stenosis or cardiac perforations.Here,we review the relevant literature and present the current"state-of-the-art"of left atrial anatomy,PV ostia as well as the clinical aspects of refractory AF with MDCT imaging protocols and procedural aspects of PV ablation.     

左心耳封堵术：预防心房颤动左心耳血栓的利刃

血栓栓塞性并发症是心房颤动致死、致残的主要原因,左心耳是心房颤动患者血栓形成的主要部位。抗凝及外科手术切除左心耳副作用及创伤大,患者难以接受。经皮导管介入行左心耳封堵术是近年来进展快速的预防心房颤动血栓栓塞的方法,具有创伤小、操作简单、耗时较少等优点。作者对国内外左心耳封堵术的相关研究进展作一介绍。     

Pseudoaneurysm originating from left ventricle aneurysm: An autopsy case and review of literature

Rupture of the free wall of the left ventricle is a catastrophic complication of acute myocardial infarction. Rarely, free wall rupture is contained by overlying adherent pericardium, producing a pseudoaneurysm of the left ventricle. In this report, a case of a left ventricular pseudoaneurysm due to a previous myocardial infarction is described. A 55-year-old woman had a severe chest pain 11 months prior to death. No cardiac investigation was performed. Three days prior to death, she suffered from fatigue and weakness, and had a witnessed sudden cardiac death. At autopsy, a 8.5 × 10 × 8 cm pseudoaneurysm of the left ventricle was found. There was severe coronary artery atherosclerosis. There were extensive adhesions between pericardium and pseudoaneurysm wall. The cause of death was attributed to heart failure and resulting arrhythmia. The case illustrates the rare event of left ventricular pseudoaneurysm first diagnosed at forensic autopsy.     

Left ventricular diverticulum: A case report and review of the literature

Left ventricular diverticulum is a rare congenital left ventricular outpouchings. The disease is often diagnosed during childhood because it is frequently associated with midline thoracoabdominal defects and other congenital cardiac anomalies. Most cases are asymptomatic, often discovered incidentally. Some complications have been reported including infarction, arrhythmia, heart failure. The most severe complication is rupture of the diverticulum, which can cause a patient''s death. Therefore, this congenital defect should be detected early to assess potential risks for appropriate treatment. In this article, we report a case of a 3-month-old boy with left ventricular diverticulum diagnosed with Doppler ultrasound and cardiac MSCT. Complete resection was undertaken. The patient remained asymptomatic with good heart function 2 months after surgery.     

Myocardial uptake of technetium-99m stannous pyrophosphate in experimental viral myopericarditis.

Distribution of technetium-99m stannous pyrophosphate was studied in mice with experimentally induced viral myopericarditis. Myocardial and bone uptakes of Tc-PPi were compared in 55 mice inoculated with coxsackievirus B3 (Nancy strain). The myocardium-to-bone uptake ratio in 33 mice with myopericarditis was increased to a greater extent than that seen in 22 mice without myopericarditis (p less than 0.001). In the severely involved heart, the uptake per gram exceeded that in the bone. Myocardial uptake in myopericarditis can be visualized on a whole-body image using a pinhole collimator and a left lateral view. Our experimental studies suggest the potential clinical usefulness of myocardial scintigraphy in viral myopericarditis.     

Intrapulmonale Ruptur eines Aortenaneurysmas

Thoracic aortic aneurysms normally cause death due to either intrapericardial (cardiac tamponade) or intrapleural rupture (internal hemorrhage). There are only very few case reports on sudden unexpected death due to rupture of a thoracic aortic aneurysm into the left lung. Hemoptysis may be the first clinical symptom of a rupture of a thoracic aortic aneurysm into the lungs. In cases of rupture of a thoracic aneurysm into the lungs the cause of death is mostly fatal blood aspiration. This article reports the case of a 40-year-old man who after thoracic pain in the days before death presented in an ear nose and throat clinic (ENT) with suddenly occurring hemoptysis. The patient suddenly collapsed during the diagnostic examination and died despite emergency measures. Cause of death was a primary intrapulmonary and then intrapleural rupture of a thoracic aortic aneurysm at the site of surgical repair of aortic coarctation in childhood.     

Delayed death owing to blunt cardiac injury

Two cases of blunt myocardial injury to the region of the anterior descending branch of the left coronary artery causing death are described. In one case, direct injury appeared to have resulted in myocardial infarction, whereas in the other, cardiac arrhythmia (possibly secondary to coronary artery spasm) was implicated. Although apparently uncommon, deaths following blunt injury to the coronary arteries may cause death, but are difficult to predict and prevent.     

Mitral annulus calcification and sudden death

Mitral valve annulus calcification is a degenerative cardiac condition often found at autopsy in the elderly. While usually considered incidental to the cause of death, we report two cases where mitral valve annulus calcification with valve stenosis was associated with sudden death. Case 1: a 61-year-old female who had underlying atherosclerosis and hypertension collapsed at home. At autopsy there was marked mitral valve annulus calcification with valve stenosis and cardiomegaly. Case 2: a previously well 74-year-old female collapsed in a toilet. At autopsy there was marked calcification of the mitral valve annulus with valve stenosis. In both cases death was attributed to the effects of the calcified mitral valve annulus. Although such calcification may be unrelated to the terminal lethal mechanism, the association with left atrial enlargement, atrial fibrillation, mitral regurgitation, mitral stenosis, bacterial endocarditis, ischaemic and thromboembolic stroke, myocardial infarction, and arrhythmias, means that it should not be overlooked in the differential diagnosis in cases of sudden and unexpected death.     

An anomalous origin of left coronary artery and sudden death in a soccer player: a case report

Coronary artery anomalies, after hypertrophic cardiomyopathy, are the second most common cause of exercise-related sudden cardiac deaths. These anomalies have been associated with myocardial ischaemia, arrhythmia and sudden death during exercise. Anomalous origin of the left coronary artery from the right sinus of Valsalva with anterior or posterior courses is not always thought to be a benign anomaly. A 22-year-old man died suddenly on a football field. At autopsy, there was an abnormal origin of the left coronary artery from the right sinus of Valsalva. The abnormal course of the artery between the aorta and pulmonary trunk had limited victim's functional capacity. The history, cause of death and patho-physiology are discussed, and some preventive strategies suggested.     

肥厚型心肌病合并心律失常临床特征及治疗

目的探讨肥厚型心肌病合并心律失常的临床特征及治疗方法。方法回顾性分析2000年9月至2016年7月经心脏超声或左室造影及心电图或动态心电图证实为肥厚型心肌病(HCM)合并心律失常的105例患者临床特征及治疗方法。结果 105例患者分为肥厚型非梗阻性心肌病组(HNCM)42例,肥厚型梗阻性心肌病组(HOCM)41例,心尖肥厚型心肌病组(AHCM)22例。3组患者临床特征差异无统计学意义(P>0.05)。HCM合并心律失常类型包括窦性心动过缓、心房扑动、心房颤动、房室传导阻滞、频发房性早搏、频发室性早搏、非持续性室性心动过速、心室颤动。3组不同心律失常类型中,均为心房颤动发生率最高,分别为38.1%、63.4%及50.0%。HOCM组12例患者行经皮间隔心肌消融术,4例患者行外科肥厚心肌切除术。HNCM组4例患者行永久起搏器植入术。HOCM组2例患者因心室颤动植入单腔植入型心律转复除颤器。HNCM组、HOCM组及AHCM组分别有7例、2例及2例患者行射频消融术。出院后随访3~14个月,平均(8±3)个月,患者均存活,临床症状均明显缓解。结论 HCM合并心律失常的患者,选择适当的治疗方法,可取得良好的疗效。     

Two forensic autopsy cases of death from unexpected lesions of the pituitary gland

Herein, we report the findings of 2 forensic autopsy cases, in which unexpected pituitary lesions were the underlying cause of death.Case 1: A 56-year-old woman was found dead at her home during a cold winter spell. Macroscopic autopsy findings included a difference in the color of blood that filled her left and right cardiac chambers (deep red and dark red, respectively), collapse of both lungs, atrophy of the thyroid gland, and a large tumor arising from the sella turcica. Microscopic examination revealed a pituitary adenoma along with extensive bleeding. The cause of death was considered to be hypothermia, resulting from dysregulation of thermogenesis due to the pituitary adenoma.Case 2: An 86-year-old man with a history of pollakiuria was found dead in a bathtub, with his face and chest submerged in bathwater and his legs positioned outside the bathtub. The macroscopic findings of the autopsy included hyper-inflated lungs, fluid collection in the thoracic cavity, and aspiration of gastric contents in the bronchi. The atherosclerotic changes of the man’s coronary and cerebral arteries were considered mild for his age. Microscopic examination showed a marked infiltration of lymphocytes and plasma cells in the posterior pituitary gland, as well as in the liver, pancreas, and submandibular gland. Considering the results of the autopsy and the findings from the investigation conducted at the death scene, we concluded that the man probably lost consciousness following a neurally mediated syncope, which was induced by diabetes insipidus (lymphocytic hypophysitis). After losing consciousness, the man likely fell in the filled bathtub and then drowned.These 2 cases highlight the need for a thorough post-mortem investigation, including a microscopic examination of the pituitary gland. In addition, forensic pathologists should carefully study the pituitary gland in cases where the cause of death is thought to be related to dysfunction of thermoregulation or osmoregulation.     

The use of histology in 638 coronial post-mortem examinations of adults: an audit

An audit was performed to determine the effectiveness of histological sampling of forensic post-mortem cases based on a review of three years' data, which comprised 638 adult autopsy cases. During the study period organs and tissues that appeared macroscopically normal and abnormal were extensively sampled. Histology was regarded as in some way contributory (providing, altering or confirming a cause of death) 53% of the time. The use of histology provided the cause of death in 49 (24%) of the 203 cases not given a cause of death after the completion of the macroscopic examination. When an interim cause of death had been supplied following the completion of the gross examination it was changed in 4.8% of cases, but there were no changes of the manner of death. The majority of the histological diagnoses or discrepancies involved the lungs and the heart. All diagnoses relevant to determining the cause of death would have been made if samples had been taken only from the left ventricle, right ventricle, coronary arteries, lungs, kidneys and brain with any tissue or organ that appeared abnormal macroscopically. A macroscopically identified abnormality that appeared to have been responsible for death was not sampled in 20 cases; consequently, more attention will be paid to sampling macroscopically abnormal tissues. As a result of this audit histology sampling practice has been revised and will be re-audited in the future.     

A case of deferred death from drowning of a man found dead in bed at home

An autopsy case of deferred death from drowning is reported. A 63-year-old man was found dead wearing wet clothing in his bed at home. At a medico-legal autopsy, mud was observed in the air passages as well as in the stomach, and a total of 210 g pleural effusion was also noted in the thoracic cavity (left 70 g, right 140 g). The left and right lungs were expanded and weighed 800 g and 950 g, respectively. Histological examination revealed the pathological finding of pneumonia with the exudation of numerous leucocytes into the alveoli as well as some postmortem changes. Diatoms were detected in the liver and both lungs by the disorganization method. In addition, scene investigation disclosed that he had fallen into a ditch in front of his house and had inhaled muddy water in the ditch, and had then managed to reach his bed and survive for a while, but dying eventually from aspiration pneumonia as a result of inhalation of exogenous water. The cause of his death was, therefore, given as deferred death from drowning rather than aspiration pneumonia.     

左心耳封堵器临床研究进展

心房颤动是常见心律失常,是老年人缺血性脑卒中的主要原因之一.左心耳是非瓣膜性房颤(NVAF)形成血栓的主要部位.研究表明封堵左心耳可有效地减少NVAF患者缺血性脑卒中发作,其疗效不亚于华法林预防治疗作用.理想的左心耳封堵器是完成左心耳封堵的关键因素.经过数十年研究,目前临床上常用的左心耳封堵器有Watchman封堵器、ACP封堵器,还有部分封堵器处于临床前试验研究阶段.该文就目前左心耳封堵器研究和临床应用现状作一简要综述.     

The effect of acute pulmonary edema on pulmonary vascular resistance: significance for the interpretation of dilated upper lobe vessels on chest radiographs

Dilation of upper lobe pulmonary vessels is an important radiographic sign of acute, left heart failure. A prominent theory is that perivascular edema causes increased resistance at the lung bases and inverts the normal perfusion gradient such that upper lobe blood flow exceeds lower lobe flow. This theoretical increase in flow is thought to cause dilatation of upper lobe vessels. Previous experimental studies determined indirectly changes in resistance from changes in the perfusion gradient: Results were contradictory. We measured directly the effect of edema on resistance in isolated canine lungs. Resistance increased linearly with edema. The magnitude of increase was small, however, and insufficient to cause inversion of the perfusion gradient. Our data indicate that interstitial pulmonary edema does not cause significant redistribution of blood flow. We suggest that dilated upper lobe vessels are veins acting as pulmonary venous manometers, reflecting elevated left atrial pressure, not increased blood flow.     

A rare case of COVID-19 vaccine-induced myopericarditis in a young adult

Although extremely rare, the COVID-19 mRNA vaccine can induce myopericarditis without left ventricular dysfunction, and there have been rare reports of such incidents. However, these prior cases either did not have pericardial effusion without reduced left ventricular ejection fraction or had a more typical presentation of vaccine-induced myopericarditis such as shortness of breath or tactile temperature. We present a rare case of a 25-year-old man who developed myopericarditis following administration of the second dose of COVID-19 mRNA Vaccine. As vaccination plays a significant role in the fight against the COVID-19 pandemic, it is essential to highlight the physical manifestations of the vaccine''s potential adverse effects and risk factors to increase the general population''s awareness regarding the importance of emergent medical care.Kewyords: COVID-19, Myopericarditis, Pericardial effusion, Vaccine, Myocarditis, Pericarditis     

内脏心房异位综合征的电子束CT诊断

目的 探讨电子束CT（EBCT）在内脏心房异位综合征系统性诊断中的价值。方法 对10例内脏心房异位综合征病例进行回顾性分析。患儿年龄从7个月至17岁不等，平均9.5岁。EBCT增强单层和连续容积扫描各5例。范围自胸廓入口至中上腹。所有病例均行超声心动图和心血管造影，6例行手术。结果 （1）EBCT诊断右房异构8例，双侧形态学右房耳、右叶性对称肝、双侧动脉上支气管、双右肺及完全性肺静脉异常连接 均清晰显示，其中7例提示心内膜垫缺损、肺动脉狭窄并主动脉右弓右降，6例见右室双出口，2例见左侧膈疝。上腹均未见脾。（2）EBCT诊断左房异构2例，均见双侧形态学左房耳、左叶性对称肝、双侧动脉下支气管、双左肺、右室双出口、肺动脉狭窄、下腔静脉肝段缺如及主动脉右弓右降，1例见心内膜垫缺损。2例右上腹均见多个脾块。（3）EBCT检出异常数为116个，而心血管造影和超声分别为65和43个。6例手术所见与EBCT一致。结论 EBCT能够良好显示心脏大血管各节段的形态和连接，在对内脏心房异位综合征诊断治疗密切相关的心房形态、肺静脉异常连接的部位、肺动脉发育情况以及其他胸腹脏器异常的检出方面，具有明显优势，是1种重要的系统性诊断内脏心房异位综合征的方法。     

A fatal case considered to be due to cardiac arrhythmia associated with butane inhalation

An autopsy case of a 14-year-old boy whose death is considered to be a result of cardiac arrhythmia after butane inhalation and sample preservation for butane analysis are reported. The electrocardiogram taken in the ambulance revealed ventricular fibrillation. There were no autopsy findings as to the cause of death. n-Butane, isobutane and propane were identified in the blood, brain and lung of the cadaver by headspace gas chromatography. Based on these results, the cause of death was concluded to be cardiac arrhythmia due to butane inhalation. As a follow-up, n-butane, isobutane and propane concentrations in the blood kept at -30 degrees C showed the unchanged values with a coefficient of variation of within 10% for 2 weeks.     

Recurrent atrial fibrillation with nausea and vomiting

Atrial fibrillation occurred twice during episodes of severe nausea and vomiting in a previously healthy 40-year-old male with new onset of Meniere's syndrome (tinnitus, vertigo, deafness). No organic cause was identified to explain the arrhythmia. Holter monitoring, maximal treadmill stress testing, and sinus node recovery times were normal. Intense vagal stimulation, subsequent bradycardia, and dispersion of atrial tissue refractory period is the likely explanation for this arrhythmia.     

Postmortem magnetic resonance imaging (PMMRI) demonstration of reversible injury phase myocardium in a case of sudden death from acute coronary plaque change

We report a case of sudden death from acute coronary plaque change in which postmortem magnetic resonance imaging (PMMRI) detected reversible injury phase myocardium. Postmortem computed tomography (PMCT) of the chest showed diffuse ground-glass attenuation (GGA) in both lungs, suggesting pulmonary edema due to cardiac pump failure. T2-weighted imaging (T2WI) of PMMRI delineated the left anterior descending coronary artery (LAD) territory as showing high signal intensity relative to the remaining myocardium. Therefore, we presumed the cause of death was myocardial infarction (MI) of the LAD territory. Autopsy showed acute plaque change in the LAD, however, there were no indications of MI. In this case, autopsy imaging using PMCT and PMMRI was useful as a guide for autopsy.