2004 Summer Meeting - Amsterdam - The Pathological Society of ...

97
Cardiomyopathy and Intravascular Involvement of Gut in
Systemic Senile Amyloidosis
S Haider 1 , M Lesna 1 , PJ Gallagher 2
1 Royal Bournemouth Hospital, Bournemouth, United Kingdom, 2
Southampton University Hospital, Southampton, United Kingdom
In 1956 Symmers reported that the gastrointestinal tract was involved in 70% of
cases of primary amyloidosis. Since that time it has been infrequently
mentioned in the literature.
Cardiac amyloidosis is rare and presents as a restrictive cardiomyopathy or low
output cardiac failure. Despite the advances in cardiac imaging techniques,
tissue diagnosis usually requires an endomyocardial biopsy.
We have analysed the data from 9 cases of systemic amyloidosis collected over
a period of 10 years; 6/9 had an autopsy, 3/9 were diagnosed histochemically in
biopsy samples. The age of the patients varied from 74 to 97 years, all but one
were males.
Our study has shown a frequent association of cardiac amyloidosis with
intravascular amyloid in the sub mucosal arterioles and venules of the gut,
particularly of stomach. In the heart the amyloid was deposited in the basement
membrane of the myocardial cells and media of the arterioles. There were
similar intravascular deposits in the medium sized blood vessels of lungs and
kidneys but the glomeruli were spared.
We propose that in certain cases of restrictive cardiomyopathy, endomyocardial
biopsy could be replaced by less demanding gastric biopsy if amyloidosis is
considered to be a cause.
98
An Investigation Into The Relationship Between Sudden
Unexpected Cardiac Death And Lung Weight
E Beeson , R. E Owers , P. J Gallagher , M Walker
Pathology Department, Southampton University Hospitals Trust,
Southampton, United Kingdom
Sudden unexpected cardiac death (SUCD) is an important cause of mortality in
developed countries with a frequency of 10.5-13 per 100,000 populations per
annum in the UK. At post mortem pulmonary oedema is found in many, though
not all, cases of SUCD. In this study we have investigated the relationship
between pulmonary oedema and demographic, clinical and pathological
findings. Our particular objective was to relate pulmonary oedema to the degree
of certainty of cardiac death.
Data was taken from observed autopsies and past autopsy records of 990
Southampton cases over a 38 month period. Each cardiac death was classified
into one of five categories. For example definite cardiac deaths (certainty grade
1) had fresh myocardial infarction or recent coronary thrombosis whilst sudden
arrhythmic death syndrome cases (SADS, grade 5) had no cardiac
abnormalities). Up to 14 other variables were recorded and compared with lung
weight using Minitab.
There was no relationship between lung weight and the degree of certainty of
cardiac death. In particular there was no evidence that lung weight was higher
in patients with definite evidence of infarction or thrombosis. Lung weights
were higher in males. Heart weights were higher in patients with a history of
previous infarction or hypertension and in patients taking diuretics, ACE
inhibitors, aspirin and statins but this did not apply to beta blockers or calcium
channel blocking agents.
This study has not added significantly to our understanding of cardiogenic
pulmonary oedema at post mortem. We believe that we have studied adequate
numbers of cases and that our data base is sound. The cause of post mortem
pulmonary oedema is largely unexplained.
99
ATRIAL MORPHOLOGY DOES NOT PREDICT THE
ONSET OF POSTOPERATIVE ATRIAL FIBRILLATION
RJ Flavin , B Foley , J Cosgrave , D.S. O'Briain , E Fitzpatrick ,
K Bennett , E McGovern , M Tolan , V Young , P Crean , M Walsh
St.James's Hospital and Trinity College Medical School, Dublin, Ireland
Atrial fibrillation remains the commonest complication of cardiac surgery.
Prophylactic therapies have been studied but their utility has been limited by the
inability to accurately identify patients who will develop this complication.
Recent studies have suggested that atrial myolysis or lipofuscin pigmentation
predict atrial fibrillation.
To determine whether there is an association between pre-operative atrial
morphology and subsequent post coronary artery bypass surgery (CABG) atrial
fibrillation, samples of right atrial appendage were obtained from 94 patients
undergoing CABG. Tissue was formalin fixed and paraffin embedded. Four µm
sections were cut and stained with H&E. Sections were examined for the
following parameters: fibrosis, myolysis, inflammation, nuclear size, pericardial
exudates, lipofuscin pigment, arteriolar hypertrophy, contraction banding,
mesothelial hyperplasia and atrial diverticulae. Results were graded into absent,
mild, moderate or severe. Slides were reviewed by two independent observers
who were blinded to the clinical outcomes. Univariate and multivariate analysis
were carried out.
39% of the patients developed atrial fibrillation. No correlation was found
between the 10 features assessed including myolysis and lipofuscin
pigmentation and the development of atrial fibrillation.
In conclusion, conventional microscopy provides no evidence of a
morphological basis in the right atrial appendage for post-operative atrial
fibrillation.
100
Sudden Maternal Death Due To Cardiovascular Causes
GC Behrendt 1 , AG Nicholson 1 , SB Lucas 2 , MN Sheppard 1
1 Royal Brompton Hospital, London, United Kingdom, 2 St Thomas
Hospital, London, United Kingdom
Introduction: Between 89-126 cases of maternal deaths occur each
year in the UK and there has been criticism of autopsy reports in these deaths 1 .
Obvious causes linked to pregnancy are common but the hemodynamic changes
associated with pregnancy may worsen pre-existing cardiovascular disorders,
which may or may not be established before autopsy. Pathologists need to be
aware of these.
Material We examined cardiovascular causes of maternal deaths in our files
referred to our hospital between 1995 and 2003. 14 cases were identified and
slides and reports reviewed. Additional clinical information was requested
where necessary.
Results: The following causes of death were found: Eisenmengers syndrome
due to (operated) congenital heart disease (4), thrombotic microangiopathies
(3), idiopathic myocardial fibrosis (1), peripartum cardiomyopathy (1), sudden
adult death (1), floppy mitral valve (1), pulmonary arterio-venous malformation
(1), coronary artery dissection (1) and chronic recurrent thromboembolic
disease (1).
Discussion: A variety of common and rare cardiovascular disorders
can cause death in pregnancy or post-partum. Detailed examination of heart and
lungs including histology is necessary as some cases show subtle pathologic
changes.
Reference List
1. Why Mothers Die? 1997-1999 Confidential Enquiry into Maternal Deaths in
the United Kingdom. Royal College of Obstetricians and Gynaecologists Press
London 2001. p27-45.
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