4, The Joint Commission Journal on Quality and Patient Safety, Vol. Contribution of Forensic Analysis to Shark Profili ATP- binding cassette, subfamily C (CFTR/MRP), member 9 [ABCC9], Emerin (Emery-Dreifuss muscular dystrophy) [EMD], Eyes absent homolog 4 (Drosophila) [EYA4], Fukuyama-type congenital muscular dystrophy (fukutin)1 [FCMD], Sarcoglycan, d (dystrophin-associated glycoprotein) [SGCD], GATA-binding protein 4 GLA galactosidase, a [GATA4], Myosin, light chain 2, regulatory, cardiac, slow [MYL2], Myosin, light chain 3, alkali; ventricular, skeletal, slow [MYL3], Protein kinase, AMP-activated, 2 noncatalytic subunit [PRKAG2], Protein tyrosine phosphatase, nonreceptor type 11 [PTPN11], V-raf-1 murine leukemia viral oncogene homolog 1 [RAF1], A kinase (PRKA) anchor protein (yotiao) 9 [AKAP9], Potassium voltage-gated channel, Isk-related family, member 1 [KCNE1], Potassium voltage-gated channel, Isk-related family, member 2 [KCNE2], Potassium voltage-gated channel, subfamily H (eag-related), member 2 [KCNH2], Potassium inwardly rectifying channel, subfamily J, member 2 [KCNJ2], Potassium inwardly rectifying channel, subfamily J, member 5 [KCNJ5], Potassium voltage-gated channel, KQT-like subfamily, member 1 [KCNQ1], Sodium channel, voltage-gated, type IV, b [SCN4B], Calcium channel, voltage-dependent, a 2/d subunit 1 [CACNA2D1], Calcium channel, voltage-dependent, b 2 subunit [CACNB2], Glycerol-3-phosphate dehydrogenase 1like [GPD1L], Hyperpolarization-activated cyclic nucleotidegated potassium channel 4 [HCN4], Potassium voltage-gated channel, Shal-related family, member 3 [KCND3], Potassium voltage-gated channel, Isk-related family, member 3 [KCNE3], Potassium inwardly rectifying channel, subfamily J, member 8 [KCNJ8], RAN guanine nucleotide release factor [RANGRF], Sodium channel, voltage-gated, type I, b [SCN1B], Sodium channel, voltage-gated, type III, b [SCN3B], c. Catecholaminergic polymorphic ventricular tachycardia (CPVT), Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Lebanon, Department of Anatomy and Regenerative Biology, School of Medicine and Health Sciences, George Washington University, USA, Department of Biomedical Sciences, Faculty of Medicine and Medical Sciences, Balamand University, Lebanon, American Center for Investigative Cardiology Silver Spring, USA. Despite the great advantages of these techniques, one adverse event is thrombi dislodgement and the inability to differentiate between pre and post mortem thrombi. 10, The British Journal of Radiology, Vol. By making research easy to access, and puts the academic needs of the researchers before the business interests of publishers.

An abnormal thickening of the coronary arterioles can also be noted [27, 28]. Cannabis is another commonly abused drug that it is becoming more legalized in many countries. 0000012411 00000 n Minimally invasive or non-invasive autopsy methods have been recently developed and implemented to substitute clinically invasive autopsy. 101, No. When dealing with a heart autopsy, several steps are required; the pericardium should be checked for abnormalities, the pulmonary arteries should be examined for the presence of an embolus, and the patterns of origins of coronary arteries and their distributions are thoroughly investigated to determine a possible luminal obstruction. HVn7~1E@ Dvg(T6*ZvCrrn~'TjQDh*ZIM j|TGB!-g:/ ua. On the other side, the introduction of the alternative postmortem imaging techniques has recently replaced to a great extent the use of clinical autopsy. Serology, or testing that identifies antibodies in the blood, can also help guide diagnosis. 289, No. Its ECG pattern is associated with an elevated ST segment that develops either unexpectedly or as a result of the administration of sodium channel blockers [37].

Common genetic mutations associated with inherited cardiac diseases. On the other hand, next whole-exome sequencing (WES) is a new available genetic testing technique that may become an important part in post mortem studies in the future [41]. The left and right atria should be opened and their respective cavities should be thoroughly investigated and the assessment of the patency of the foramen ovale is followed [9]. 3, International Journal of Legal Medicine, Vol. Brief introduction to this section that descibes Open Access especially from an IntechOpen perspective, Want to get in touch? 1, International Journal of Legal Medicine, Vol. 2017 The Author(s). 41, No. 1, Diagnostic and Interventional Imaging, Vol. The most significant consequence of this shift is the increased frequency of clinical diagnostic discrepancies of class I and class II. *Address all correspondence to: aj00@aub.edu.lb.

). Minimally invasive autopsy: an alternative to conventional autopsy? Therefore, if SCD occurs in early ischemia before this time frame, these changes will not be detected neither histologically nor macroscopically. Cardiac atrophy is seen in autopsy as a result of myocyte apoptosis [18]. In rare cases, a vegetative embolus may lodge in a coronary artery which can be the cause of SCD, in these circumstances the embolus has the same characteristic microscopic picture of the original vegetation [5]. 2, No. 5, Yearbook of Pathology and Laboratory Medicine, Vol. ); and Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland (P.M.F. The appropriate steps when dealing with sudden cardiac Death. Misinterpretation is one of the major pitfalls of radiological examination. mgEIzid1>ne0P h`Rh`Ph`P`40i(P`Y %$Ea004`9 |)'Q!p 4, Journal of Forensic Radiology and Imaging, Vol. 0000006164 00000 n 212, No. For this purpose, the Association for European Cardiovascular Pathology has developed guidelines for autopsy investigation for SCD cases. Histological investigations are carried by examining the obtained tissues after staining with hematoxylin and eosin and Masson trichrome stain [16]. For instance, the lack of funding from insurance companies and other payers for advocating postmortem genetic testing made the molecular autopsy less frequent or less practiced by forensic pathologists [47]. endstream endobj 72 0 obj <>/OCGs[75 0 R]>>/OpenAction 73 0 R/PageLayout/SinglePage/Pages 68 0 R/Type/Catalog>> endobj 73 0 obj <> endobj 74 0 obj <>/Font<>>>/Fields 64 0 R>> endobj 75 0 obj <>>>>> endobj 76 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/Type/Page>> endobj 77 0 obj <> endobj 78 0 obj <> endobj 79 0 obj <>stream Computed tomography (CT) and Magnetic resonance imaging (MRI) are two imaging modalities that are increasingly used in postmortem investigation of SCD [17].

Additional tests that might support the presence of myocarditis include: Many disease processes can be observed only by study of the patients tissues, including under a microscope. The lack of the financial support and direct reimbursement of the pathologists on their services is the major driving force to this decline. More studies and research are still warranted to establish the validity and limitations of postmortem radiology in the identification of SCD. 3, Journal of Forensic Radiology and Imaging, Vol. 7-8, Clinical Microbiology and Infection, Vol. In coarctation of the aorta, stenosis is observed proximal to the ductus arteriosus and distal to the left subclavian artery, this impedes the normal flow of blood through the aorta. All Rights Reserved. Moreover, Microscopic findings in HCM include myocardial fiber disarray and myocytes hypertrophy which is associated with 4 fold increase in cell and nuclear size. 4, Forensic Science, Medicine, and Pathology, Vol. 0000007468 00000 n This molecular technique, could detect mutations in the genes coding for potassium channels (KCNQ1, KCNH2), sodium channels (SCN5A), and the RYR2 gene which causes tachycardia (CPVT) [39, 40]. It has been noted that patients with chronic kidney disease, obstructive sleep apnea and seizure disorders had a higher risk of developing SCD [2]. They are classified into two subcategories: (1) cardiac channelopathies that are caused by mutations affecting different cardiac membrane channels such as Long QT syndrome (LQTS), Short QT syndrome (SQTS), and Brugada syndrome (BrS) or cellular structure resulting in dysregulated Ca2+ release including catecholaminergic polymorphic ventricular tachycardia (CPVT) [34, 35], and (2) cardiomyopathies such as hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic cardiomyopathy (AC) and others. | Site Map.

Epidemiologically, CAD is responsible for 80% of the cases of SCD, cardiomyopathies account for 1015% of the cases, while 510% of SCD are caused by inherited cardiac disorders, such as coronary artery anomalies or cardiac channelopathies [6]. More importantly and in the line of autopsy practice, pathologists are facing difficulties in the lack of standardizations of sudden death coding and the variation of SD definition among different regions and countries that hinder their task in determining the precise cause of sudden death. Additionally, the inconsistency in the routine autopsy practice among hospitals, university medical centers and forensic medicine institutes has also been a central issue. The latter stains may highlight areas of heart muscle injury and may even detect the presence of viral genes that are markers of viruses that can attack the heart muscle. The disease processes associated with myocarditis can only be diagnosed these direct examinations and with expert study. In the meantime, the use of non-invasive imaging approach should accompany and complement conventional autopsy procedures in order to enhance a significant advancement in the postmortem investigation of SCD (Figure 1). Other markers being tested include complement proteins like C1, C3, C8, C9 and inflammatory mediators such as CD15, IL-1, IL-6, TNF-, IL-15, IL-8, MCP-1, CD18 as well as tryptase which have shown positive results in early hours of ischemia. They can develop syncope as a result of physical activity, a strong emotional stimulus or SD secondary to Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT). 40, No. It involves the amplification of a specific DNA sequence by an enzymatic reaction. The development of collateral circulation in chronic ischemic heart disease patients has a protective role as it provides blood to areas distal to a stenotic region [18]. A Cohen coefficient analysis was performed to explore the effect of the clustered nature of the data. 4, Journal of Thoracic Imaging, Vol. Generally, the autopsy protocols of SCD start with a macroscopic study of the heart, if the cause is identified no further testing is required. Cocaine is a well-known stimulant drug of abuse that is linked to cardiac death, along with amphetamines. Ready to join the fight? 0000468118 00000 n In one cadaver, early myocardial infarction of the papillary muscles had been missed. Feldman AM, McNamara D. Myocarditis. Licensee IntechOpen. In cases related to myocardial infarction in SCD, it is important to highlight the fact that histological defects differ based on the date of infarction [25]. Forensic Science, Medicine and Pathology, Vol. 0000470317 00000 n Virtopsy, a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)a feasibility study, Post-mortem forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results, Postmortem whole-body magnetic resonance imaging as an adjunct to autopsy: preliminary clinical experience, Forensic institutes across the world place CT or MRI scanners or both into their mortuaries, Multidetector computed tomography findings in deaths with severe burns, MDCT analysis of projectile injury in forensic investigation, Advances of dual source, dual-energy imaging in postmortem CT, Postmortem angiography: review of former and current methods, Whole body postmortem angiography with a high viscosity contrast agent solution using poly ethylene glycol as contrast agent dissolver, Reduction of postmortem angiography-induced tissue edema by using polyethylene glycol as a contrast agent dissolver, Two-step postmortem angiography with a modified heart-lung machine: preliminary results, Postmortem angiography after vascular perfusion with diesel oil and a lipophilic contrast agent, Postmortem whole-body CT angiography: evaluation of two contrast media solutions, Feasibility of percutaneous organ biopsy as part of a minimally invasive perinatal autopsy, Fat embolism of the lungs as the cause of death: etiology, pathogenesis and reasoning (authors transl) [in German], Herzinsuffizienz, hypertrophie und dilatation, Postmortem imaging-guided biopsy as an adjuvant to minimally invasive autopsy with CT and postmortem angiography: a feasibility study, Postmortem unenhanced magnetic resonance imaging of myocardial infarction in correlation to histological infarction age characterization, Muslim customs surrounding death, bereavement, postmortem examinations, and organ transplants, The impact of declining clinical autopsy: need for revised healthcare policy, Low-tech autopsies in the era of high-tech medicine: continued value for quality assurance and patient safety. Exercise is a common trigger of arrhythmia in these patients. Congenital heart diseases occupy a high rank in the causes of SCD in children, with coarctation of the aorta (CoA) and transposition of the great vessels in the forefront [22]. On the other hand, genetic testing is done as the next step on victims less than 30years old with a negative macroscopic study [14]. 0000013212 00000 n

So, in summary, study of the tissues (including the use of a microscope and special molecular techniques) can reveal a wide range of disease indicators, including: The white cells play a role in fighting against cells infected by certain viruses to keep the body healthy, but they can also unintentionally damage uninfected cells, killing them as well. The prevention of SCD is a field that is continuously studied [10]; however, its rate remains high despite the various preventive measures. 127, No. Twenty corpses (four female corpses and 16 male corpses; age range, 1580 years), all of whom were reported to have had antemortem acute chest pain, were imaged with postmortem whole-body CT angiography and underwent standardized image-guided biopsy. One of these major challenges is the significant decline of autopsy rate, wherein autopsies are performed after less than 10% of all U.S death. Histologically, the classic findings of vegetation in infective endocarditis are tissue infiltration of neutrophils and fibrin deposition along with the implicated bacteria can be identified using gram stain. These radiological examination tools have become more feasible for the physicians so that they are no more obliged to ask for consent from victims next of kin which is often refused by bereaved families due to cultural and religious objections. 3, No. These signs include myofiber eosinophilia, elongation of sarcomeres and nuclei, wavy fibers, interstitial edema and contraction band. %%EOF This latter could be prescribed and non-prescribed medications, illicit or recreational drugs that are widely abused by athletes or young individuals [29]. Many reasons have been associated with this change, most importantly, the evolution process in the postmortem investigation tools. It is characterized by genetic mutation targeting Na+ channels [34, 35]. 0000468364 00000 n You can do this in either the Custom Facebook Feed plugin settings or in the shortcode itself. Simultaneous cardiac anomalies can also accompany CoA, bicuspid aortic valve is being the most common, therefore, a close examination of the heart is required [23, 24]. Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too. Thats why Myocarditis Foundation works tirelessly alongside families, patients, researchers, and physicians to support the search for understanding and for a cure. Several studies have reinforced the importance of autopsy in investigating the cause behind sudden unexplained death, the nature of cardiac disease in case of SCD, the underlying mechanism, whether it is arrhythmic or mechanical or it originates from genetic mutations, and the possibility of illicit drug abuse [9]. Basso C et al., have described in details autopsy procedures that should be followed in order to represent the minimum standard that is required in the routine autopsy practice for the adequate assessment of SCD including standard gross examination of the heart, histological sampling, toxicology and molecular examination [9]. Commonly used approaches include the use of pharmacological interventions and implantable cardioverter-defibrillator (ICD) [10]. 7, International Journal of Legal Medicine, Vol.

Even a single life lost to myocarditis is too many. In rare instances, the occurrence of SCD in acute cannabis intoxication has been described. Their proposed mechanism of action is associated with the development of myocarditis and the ability to cause a prolongation in QT interval which then progresses into a life-threatening arrhythmia [32]. Toxicological examination is also mandatory and scientifically a useful tool to determine the causes of SCD. The practice in postmortem examination involves a detailed patient and family history, questioning regarding the patients condition before death, as well as, macroscopic and histological studies of the heart with investigations of other organs to exclude non-cardiac causes of death, followed by a genetic testing of a blood sample. Postmortem radiology is a promising approach but currently cannot replace conventional autopsy. Postmortem CT angiography combined with image-guided biopsy, because of their minimally invasive nature, have a potential role in the detection of the cause of death after acute chest pain. It is considered as a major health problem worldwide accounting for 1520% of all deaths [2]. This incident is associated with the development of a ventricular tachycardia (VT) which then progresses into a ventricular fibrillation (VF) and eventually asystole is followed [1]. CV{ +?0%0}`o`n`aw``e|0X100ae`n`8xlF*8p`F&Ek rM" Myocarditis is typically considered during an autopsy only when the caring clinicians involved have a strong understanding of this diseases wide range of symptoms, an appreciation for its non-specific nature and believe it could indeed be a cause of death. 0000002002 00000 n Once the heart is evacuated from blood, multiple measurements are taken including the heart weight, its wall thickness and its dimensions [9]. startxref The Cohen coefficient was 0.94. These artifacts could be incidental and unrelated to the cause of death [51]. When their death occurs suddenly or answers about the cause arent clear, this pain persists and may multiply. Autopsy is also of vital importance in providing accurate epidemiological data and data for evaluating of the quality of care, identifying and elucidating new pathological findings, evaluating new medical interventions, improving post-marketing surveillance for adverse effects of drugs, devices, and procedures, improving cardiovascular diseases research and offering powerful tools for education [46, 47]. 0000012504 00000 n We also gave insight into the new radiological techniques, their advantages and related diagnostic pitfalls as compared to that of conventional autopsy. As PhD students, we found it difficult to access the research we needed, so we decided to create a new Open Access publisher that levels the playing field for scientists across the world. The cutting and staining of the tissues includes standard stains and as well as what are called special stains. Such tissues are taken in a systematic way from the heart including from the heart muscle of the pumping chambers called ventricles. 6, Forensic Science, Medicine, and Pathology, Vol. Polymerase chain reaction (PCR) is one example of the postmortem molecular investigation techniques. The underlying cardiac causes of SCD include coronary artery diseases (CAD), valvular heart diseases, cardiomyopathy syndromes, infiltrative diseases of the myocardium, myocarditis, infective endocarditis, inherited ion channels defects and congenital heart diseases [4, 5]. The current genetic techniques allow us to unmask the etiology behind SCD. In seven of 20 cadavers, CT-guided biopsy provided additional histopathologic information that substantiated the final diagnosis of the cause of death. It has been indicated that LQTS1 is triggered by exercising such as swimming, LQRTS2 by sudden loud noises such alarms, while LQTS3 occurs during sleep or at rest [34, 35]. SQTS is considered as the severest condition of cardiac channelopathies. Results show that cardiac parameters measured by PMMR may differ from the measures obtained by autopsy and forensic pathologists should be aware of these differences. 4, Journal of Forensic Radiology and Imaging, Vol. 0 0000004818 00000 n Please enter the Page ID of the Facebook feed you'd like to display. At least 64 genes have been identified to cause cardiomyopathies syndromes [36]. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. 0000008691 00000 n 202, No. To ensure that an adequate WES testing is being performed, it is recommended to use about 5 to 10ml of blood collected for DNA testing or 5g of tissue extracted from the heart or spleen [36]. Certain shapes of waves or tracings seen on ECGs, or the rate and rhythm of the heart as reflected on the ECG may point to the possibility of myocarditis. 4, Annals of Anatomy - Anatomischer Anzeiger, Vol. This technique allows us to study the whole genetic library of an individual DNA sample, which is more effective and better than studying a specific gene. 3, Obesity Science & Practice, Vol. If antibodies to known common viral, bacterial, and other infectious agents that cause myocarditis, it may indicate such a cause of myocarditis. Hair from the back of the scalp or pubic hair should also be used for doing toxicological analysis [9]. 8, No. Therefore, toxicological analysis is to be considered as a cornerstone in postmortem studies, in order to screen for potential ingestion of medications that are linked to cardiac side effects and to look for possible intoxication of drug of abuse. Although its associated side effects are typically low, it causes cardiovascular side effects. Referring to the guidelines adapted by the Society of Forensic Toxicologists and the American Academy of Forensic Sciences [33], multiple samples should be studied including heart blood, peripheral blood collected from the femoral vein, urine or bile. Additionally, there are still no gold standards that currently exist for postmortem radiological examination of cardiovascular pathologies. Next Generation Sequencing (NGS) is also new available genetic sequencing technique for detecting channelopathies associated-mutations, which has a sensitivity of 72% for LQTS cases [42]. 0000006067 00000 n 0000001242 00000 n C5b-C9 complex, which is the last creation of the activated complement cascade that forms the membrane attack complex (MAC), is a specific marker for early necrosis. However, cardiologists seem unsatisfied with the new non-invasive imaging techniques and still believe in the traditional autopsy as a gold standard in diagnosis of cardiovascular diseases. In fact, studies have shown that clinicians and pathologists have no more incentives to perform the autopsy and they are focusing on the new imaging approaches [48]. Positive results are followed by non-invasive imaging techniques like echo, CT, MRI among others or invasive ones like angiography and electrophysiological studies [12]. 71, International Journal of Legal Medicine, Vol. If the address matches an existing account you will receive an email with instructions to reset your password. Home > Books > Post Mortem Examination and Autopsy - Current Issues From Death to Laboratory Analysis, Submitted: May 15th, 2017 Reviewed: October 9th, 2017 Published: December 27th, 2017, Total Chapter Downloads on intechopen.com. It has also overcome some families religious objections [13]. The change in economic landscape has led both the public and the private healthcare sectors to increase focus on cost control [48]. Similarly for the case of autopsy reports, there should be nationally uniform criteria and standards for reporting autopsy findings. Pathologists, especially with specialist training, can undertake histological analysis of tissues with a microscope.