Aortic root morphometry revisited-Clinical implications for aortic valve interventions.

The complex anatomy of the aortic root is of great importance for many surgical and transcatheter cardiac procedures. Therefore, the aim of this study was to provide a comprehensive morphological description of the nondiseased aortic root. We morphometrically examined 200 autopsied human adult hearts (22.0% females, 47.9 ± 17.7 years). A meticulous macroscopic analysis of aortic root anatomy was performed. The largest cross-section area of the aortic root was observed in coaptation center plane (653.9 ± 196.5 mm2), followed by tubular plane (427.7 ± 168.0 mm2) and basal ring (362.7 ± 159.1 mm2) (p < 0.001). The right coronary sinus was the largest (area: 234.3 ± 85.0 mm2), followed by noncoronary sinus (218.7 ± 74.8 mm2) and left coronary sinus (201.2 ± 78.08 mm2). The noncoronary sinus was the deepest, followed by right and left coronary sinus (16.4 ± 3.2 vs. 15.9 ± 3.1 vs. 14.9 ± 2.9 mm, p < 0.001). In 68.5% of hearts, the coaptation center was located near the aortic geometric center. The left coronary ostium was located 15.6 ± 3.8 mm above sinus bottom (within the sinus in 91.5% and above sinutubular junction in 8.5%), while for right coronary ostium, it was 16.2 ± 3.5 mm above (83.5% within sinus and 16.5% above). In general, males exhibited larger aortic valve dimensions than females. A multiple forward stepwise regression model showed that anthropometric variables might predict the size of coaptation center plane (age, sex, and heart weight; R2 = 31.8%), tubular plane (age and sex; R2 = 25.6%), and basal ring (age and sex; R2 = 16.9%). In conclusion, this study presents a comprehensive analysis of aortic-root morphometry and provides a platform for further research into the intricate interplay between structure and function of the aortic root.

Aortic valve fenestrations: Macroscopic assessment and functional anatomy study.

Aortic valve fenestrations are defined as a loss of aortic valve leaflet tissue. They are a common but overlooked finding with unclear significance. The aim of this study was to investigate the varied functional anatomies of aortic valve fenestrations. A total of 400 formalin-fixed autopsied human hearts were macroscopically assessed and the function of the aortic valve of 16 reanimated human hearts were imaged using Visible Heart® methodologies. Aortic valve leaflet fenestrations were present in 43.0% of autopsied hearts (in one leaflet in 24.0%, in two leaflets 16.0%, in all leaflets 3.0%). Fenestrations were mostly present in left (25.5%) followed by right (23.3%) and noncoronary leaflet (16.3%). In 93.8% of cases, the fenestrations form clusters and were mainly located at the free edge of the leaflet in the commissural area (95.4%). Hearts with aortic valve fenestrations had significantly larger aortic valve diameters and aortic valve areas (p < 0.001). The average surface area sizes of fenestrations were 23.8 ± 16.6 mm2 , and the areas were largest for left followed by right and noncoronary leaflet fenestrations (p < 0.001). The fenestration areas positively correlated with donor age (r = 0.31; p = 0.02). Significant hypermobility and subjective weakening of the leaflet adhesion levels of the fenestrated regions were observed. In conclusion, fenestrations of the aortic leaflets are frequent, and their sizes may be significant. They occur in all age groups, yet their size increase with aging. Fragments of leaflets with fenestrations show different behaviors during the cardiac cycle versus unchanged areas.

Pulmonary valve morphometry revisited: Clinical implications for valvular and supravalvular interventions.

In this cadaver-based study, we aimed to present a novel approach to pulmonary valve (PV) anatomy, morphometry, and geometry to offer comprehensive information on PV structure. The 182 autopsied human hearts were investigated morphometrically. The largest PV area was seen for the coaptation center plane, followed by basal ring and the tubular plane (626.7 ± 191.7 mm2 vs. 433.9 ± 133.6 mm2 vs. 290.0 ± 110.1 mm2 , p < 0.001). In all leaflets, fenestrations are noted and occur in 12.5% of PVs. Only in 31.3% of PVs, the coaptation center is located in close vicinity of the PV geometric center. Similar-sized sinuses were found in 35.7% of hearts, in the remaining cases, significant heterogeneity was seen in size. The mean sinus depth was: left anterior 15.59 ± 2.91 mm, posterior: 16.04 ± 2.82 mm and right anterior sinus: 16.21 ± 2.81 mm and the mean sinus height: left anterior 15.24 ± 3.10 mm, posterior: 19.12 ± 3.79 mm and right anterior sinus: 18.59 ± 4.03 mm. For males, the mean pulmonary root perimeters and areas were significantly larger than those for females. Multiple forward stepwise regression model showed that anthropometric variables might predict the coaptation center plane (sex, age, and heart weight; R2  = 33.8%), tubular plane (sex, age, and BSA; R2  = 20.5%) and basal ring level area (heart weight and sex; R2  = 17.1%). In conclusion, the largest pulmonary root area is observed at the coaptation center plane, followed by the basal ring and tubular plane. The PV geometric center usually does not overlap valve coaptation center. Significant heterogeneity is observed in the size of sinuses and leaflets within and between valves. Anthropometric variables may be used to predict pulmonary root dimensions.

Microanatomy of the myocardial extensions of the pulmonary valve in light of modern catheter ablation methodology.

INTRODUCTION: The muscular sleeves (or myocardial extensions) derived from the right ventricle infundibulum myocardium are considered the true anatomic substrate for right ventricular outflow tract arrhythmias. METHODS: Pulmonary valve specimens obtained from 65 donors (24.6% females, mean age 45.9 ± 15.8 years) were investigated micro-anatomically. Specimens were histologically processed, stained with Masson's Trichrome, and examined under a light microscope. RESULTS: The myocardial extensions were present in the left anterior pulmonary valve sinus in 86.2% of cases, in the right anterior sinus in 89.2% of cases and in 90.7% of cases in the posterior sinus (p = .699). In 69.2% of examined hearts, the myocardial extensions were present in all sinuses. The mean height of the extensions was 4.12 ± 1.76 (left anterior) versus 3.69 ± 1.47 (right anterior) versus 4.28 ± 1.73 mm (posterior) (p = .137). The myocardial extensions occupied an average of 28.9 ± 10.4% of the left anterior sinus, 26.7 ± 11.2% of the right anterior sinus, and 31.9 ± 11.3% of the posterior sinus (p = .044). Sleeves extending beyond the fibro-arterial transition zone were present in at least one sinus in 33.8% of hearts (in 7.7% (5/65) of the left and right anterior sinuses and 21.5% (14/65) of posterior sinus, p = .021). CONCLUSIONS: The myocardial extensions of the pulmonary valve are common anatomical entities. Although the length of the myocardial sleeves is similar in all pulmonary valve sinuses, their relative extent is greatest in the posterior sinus. Long sleeves that spread beyond the fibro-arterial transition zone were observed in one-third of hearts, predominantly in the posterior sinus. Myocardial and fibrous tissue layer thicknesses varied considerably.

Morphology of the Left Atrial Appendage: Introduction of a New Simplified Shape-Based Classification System.

BACKGROUND: The left atrial appendage (LAA) is a heart structure with known prothrombogenic and pro-arrhythmogenic properties. AIM: The aim of this study was to evaluate the specific anatomy of the LAA and to create a simple classification system based on the shape of its body. METHOD AND RESULTS: This study investigated 200 randomly selected autopsied human hearts (25.0% females, 46.6±19.1 years old). Three (3) types of LAAs were distinguished: the cauliflower type (no bend, limited overall length, compact structure [36.5%]); the chicken wing type (substantial bend in the dominant lobe [37.5%]), and the arrowhead type (no bend, one dominant lobe of substantial length [26.0%]). Additional accessory lobes were present in 55.5% of all LAAs. Significant variations between category types were noted in LAA length (chicken wing: 35.7±9.8 mm, arrowhead: 30.8±10.1 mm, cauliflower: 22.3±9.6 mm [p<0.001]) and in the thickness of pectinate muscles located within the LAA apex (arrowhead: 1.2±0.7 mm; cauliflower: 1.1±0.6 mm; chicken wing: 0.9±0.6 mm [p<0.001]). Left atrial appendage volume and orifice size were not affected by the type of LAA shape. The age of the donor was positively correlated with LAA volume (r=0.29, p=0.005), body length (r=0.26, p=0.012), and area of the orifice (r=0.36, p<0.001). Donors with an oval LAA orifice were significantly older than those with round orifices (50.2±16.6 vs 43.7±20.4 years [p=0.014]) and had significantly heavier hearts (458.2±104.8 vs 409.6±114.1g [p=0.002]). CONCLUSIONS: This study delivered a new simple classification system of the LAA based on its body shape. An increase in age and heart weight was associated with LAA enlargement and a more oval-shaped orifice. Results of current study may help to estimate the different thrombogenic properties associated with each LAA type and be an assistance during planning and performing interventions on LAA.

Anatomy of the left atrial ridge (coumadin ridge) and possible clinical implications for cardiovascular imaging and invasive procedures.

BACKGROUND: The left atrial ridge is a structure located in the left atrium between the left-sided pulmonary veins ostia and the orifice of the left atrial appendage. Since it was commonly misdiagnosed as a thrombus, the ridge is also known as the "coumadin" or "warfarin" ridge. The left atrial ridge is a potential source of arrhythmias and can be an obstacle in ablation procedures. This study aimed to provide information about the occurrence and spatial morphometric characteristics of the left atrial ridge. METHODS AND RESULTS: The macroscopic morphology of the left atrial ridge was assessed in 200 autopsied human hearts. The ridge was observed in 59.5% of specimens and was absent in the remaining 40.5% of cases. The mean length of the ridge was 22.4 ± 5.1 mm. It was wider at its inferior sector when compared to its superior sector (9.1 ± 5.0 vs 7.9 ± 3.2 mm; P = .028). The total wall thickness measured at the cross section of the ridge was significantly larger in the inferior than in superior sector (6.2 ± 3.5 vs 4.3 ± 1.8 mm; P < .001), although the myocardial thickness was significantly larger at the superior sector (3.1 ± 1.4 vs 1.9 ± 0.9 mm in inferior sector, P < .001). CONCLUSION: The left atrial ridge is a variable structure, present in 59.5% of humans. The ridge is significantly wider and thicker at its inferior sector, although the actual myocardial layer present within the ridge is thinner at this location. Knowledge about the left atrial ridge morphology is key in avoiding unnecessary interventions or complications during invasive procedures.

Deep septal deployment of a thin, lumenless pacing lead: a translational cadaver simulation study.

AIMS: The recently introduced technique of direct transseptal pacing of the left bundle branch is poorly characterized with many questions with regard to the optimal implantation strategy and safety concerns largely left unanswered. We developed a cadaver model for deep septal lead deployment in order to investigate the depth of penetration in relation to lead behaviour, lead tip position, and the number of rotations. METHODS AND RESULTS: Five fresh human hearts and five lumenless, 4.1-Fr pacing leads were used for deep septal deployment simulations. The leads were positioned with the use of a dedicated delivery sheath and screwed into the interventricular septum at several sites progressively more distal from the atrioventricular ring with a predetermined number of lead rotations. During each lead deployment, the depth of tip penetration was measured and the lead behaviour was noted. Four distinct lead behaviours were observed: (i) helix only penetration, no matter how many rotations were performed, due to the 'endocardial entanglement effect' (43.1% cases) or (ii) 'endocardial barrier effect' (19.6% cases), (iii) shallow/moderate penetration, with ensuing 'drill effect' when more rotations were added (9.8% cases), and (iv) deep progressive penetration with each additional rotation, occurring when the 'screwdriver effect' was present (27.4% cases, including three septal perforations). These different lead behaviours seemed to be determined by the lead position-mainly the strength of the initial endocardial layer-and the number of fully transmitted rotations. CONCLUSION: New insights into deep septal lead deployment technique were gained with regard to safe and successful implantation.

Morphology of the Vieussens valve and its imaging in cardiac multislice computed tomography.

INTRODUCTION: To deliver accurate morphological descriptions of the Vieussens valve (VV) and to investigate whether this structure could be visualized using standard contrast-enhanced electrocardiogram-gated multislice computed tomography (MSCT). METHODS: A total of 145 human autopsied hearts and 114 cardiac MSCT scans were examined. RESULTS: The VV was observed in both study groups, however, the detection rate was significantly worse in the MSCT examination (18.4% in MSCT vs 62.1% in cadavers, P < .0001). The VV height was larger in MSCT patients (2.8 ± 1.2 vs 5.4 ± 1.7 mm; P < .0001). No significant difference was found in the measured distance between the VV and the coronary sinus ostium between the two separate subgroups (27.3 ± 9.5 vs 24.4 ± 5.8 mm; P = .18). In autopsied material the most frequent valve location was the anterior wall of the coronary sinus (43.3%); the same was observed in MSCT scans (71.4%). CONCLUSION: The VV is a common heart structure, present in over 60% of humans, located mainly on the anterior and superior circuit of the coronary sinus, with relatively high morphological variability. Large VVs, which pose a significant obstacle in catheterization procedures, may be visualized using standard-protocol contrast-enhanced cardiac MSCT.

Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line.

Electric isolation of the left atrial appendage (LAA) and linear ablations in the area of the LAA base are gaining popularity. However, very little is known about the myocardial architecture and the presence of epicardial blood vessels within this region, which could significantly influence the course of such procedures. We examined 200 autopsied hearts (22.5% females, 46.7 ± 16.8 years old). The LAA isthmus (i.e., the line between the LAA ostium and the mitral annulus) was cut longitudinally. The myocardium was thickest at the LAA end of the isthmus (2.4 ± 0.7 mm) followed by its middle sector (2.1 ± 0.7 mm) inside the LAA, 5 mm from its ostium (1.9 ± 0.7 mm), and the mitral annulus end of the isthmus (1.8 ± 0.6 mm) (P < 0.0001). At least one artery was found in 96.5% of all samples (89.5% were single branched, 7% had two branches). The great cardiac vein was found in 77.0% and the left marginal vein in 2.5%. The artery was interposed between the endocardium and the great cardiac vein in 31.5% of cases. The smallest distance between the endocardium and the artery was 0.5 mm and between the endocardium and the vein was 0.7 mm. In total, we were able to distinguish fifteen different types of vascular arrangements within the LAA isthmus line in this study. The myocardium within the LAA isthmus is thickest at its LAA end. The left circumflex coronary artery branches are the most frequently-occurring vessels within the isthmus and are present in almost all cases, while the great cardiac vein is present in three quarters of hearts. Clin. Anat. 31:1024-1030, 2018. © 2018 Wiley Periodicals, Inc.

Homicides with corpse dismemberment in the material collected by the Department of Forensic Medicine, Krakow, Poland.

Aim of the study: To determine the circumstances which can be useful for offenders profiling in homicide cases with victim's body dismemberment. Material and methods: Study of all homicide cases with victim's corpse dismemberment examined in Krakow Department of Forensic Medicine over the last 50 years. Results: Within the past 50 years, a total number of 30 cases of homicides with dismembered bodies were examined in Krakow. 22 cases represent defensive mutilations performed by offender, 3 cases can be classified as offensive muti-lations and 3 cases represent aggressive mutilations - decapitation as a method of committing homicide. In this period the only 1 case of necrophilic mutilations was examined, when the body was dismembered without murder. In most cases the background of homicide was the family conflict, 6 was cause of mental illness of perpetrator and in 3 was sexual motive. Only in 3 cases (from 25 when the offender was known) perpetrator kill a stranger. In the other the offender belonged to the family or friends of the victim. In all cases where the perpetrator was determined, homicide and dismemberment was performed in his place of residence. The findings of the Police investigations indicate that in most cases homicides were not planned, occurred under the influence of emotion, only two have been previously scheduled. Conclusions: Homicides with corpses dismemberment usually are committed by offenders who is in close relationship with victim (family or friend). Dismemberment is almost always performed in the same place as murder - home of perpetrator. This type of homicide usually is not planned.

Morphology of the mural and commissural atrioventricular junction of the mitral valve.

OBJECTIVE: This study investigates mitral annular disjunctions (MAD) in the atrial wall-mitral annulus-ventricular wall junction along the mural mitral leaflet and commissures. METHODS: We examined 224 adult human hearts (21.9% females, 47.9±17.6 years) devoid of cardiovascular diseases (especially mitral valve disease). These hearts were obtained during forensic medical autopsies conducted between January 2018 and June 2021. MAD was defined as a spatial displacement (≥2 mm) of the leaflet hinge line towards the left atrium. We provided a detailed morphometric analysis (disjunction height) and histological examination of MADs. RESULTS: MADs were observed in 19.6% of all studied hearts. They appeared in 12.1% of mural leaflets. The P1 scallop was the primary site for disjunctions (8.9%), followed by the P2 scallop (5.4%) and P3 scallop (4.5%). MADs were found in 9.8% of all superolateral and 5.8% of all inferoseptal commissures. The average height for leaflet MADs was 3.0±0.6 mm, whereas that for commissural MADs was 2.1±0.5 mm (p<0.0001). The microscopical arrangement of MADs in both the mural leaflet and commissures revealed a disjunction shifted towards left atrial aspect, filled with connective tissue and covered by elongated valve annulus. The size of the MAD remained remarkably uniform and showed no correlation with other anthropometric factors (all p>0.05). CONCLUSIONS: In the cohort of the patients with healthy hearts, MAD is present in about 20% of all studied hearts. The MADs identified tend to be localised, confined to a single scallop. Moreover, MADs in the commissures are notably smaller than those in the mural leaflet.

[An unusual case of suicidal carbon monoxide poisoning committed using a portable barbecue grill]. / Niecodzienny przypadek samobójczego zatrucia tlenkiem wegla przy uzyciu przenosnego grilla ogrodowego.

Fatal carbon monoxide poisoning is relatively often encountered in medico-legal practice. Although we usually deal with events of an accidental nature, cases of suicidal character are also quite common, both in Poland and in other European countries. The source of a poisonous gas that is used by a suicide to take his life are usually exhaust fumes from cars and home gas water-heaters that are released in closed spaces. In the present report, the authors present an atypical case--the only such instance in the history of the Krakow Department--where a high carbon monoxide concentration level was achieved by burning briquetted coal in a typical portable barbecue grill. A 65-year old male lit the grill in a room locked from inside, where he had previously sealed all cracks and vents; he left a written message by the entrance where he warned his flatmates about the presence of gas. The investigation determined that the predominant underlying reason of his committing suicide were health problems. As it follows from the analysis of literature on the subject, despite extensively available materials, such a suicide method is exceptionally rare in the European or American culture, where isolated cases only are presented. On the other hand, the authors emphasize the fact that within the last score of years, using barbecue grills in suicidal poisoning has become exceedingly common in the Far East countries. The present report points to certain historical and cultural determinants that may affect such a distinct geographical polarization of the discussed method being used in some Asian countries and refers to a widely discussed by specialists significant role of mass media in popularization of such a suicide method.

[Plastic bag suffocation in material collected by Department of Forensic Medicine in Krakow]. / Uduszenie workiem foliowym w materiale Zakladu Medycyny Sadowej w Krakowie.

Cases of death resulting from placing a plastic bag on the victim's head are very rare. In the last 20 years, in the Department of Forensic Medicine in Krakow, there were fourteen such cases examined. Their number is, however, noticeably growing, amounting to as many as few cases per year. Death resulting from this mechanism is difficult from the diagnostic point of view and often the only indicative evidence is a presence of a plastic bag on the head.

Overkilling: A specific type of homicide - Constructing the definition: Perpetrator, weapon and circumstances.

Overkilling in the Forensic Medicine is known as a specific type of homicide where the number of inflicted injuries greatly surpasses the number of fatal ones. Conducted research aimed to create a unified definition of the phenomenon and its classification criteria by analysing a vast majority of variables concerning its various characteristics. From the population of homicide victims autopsied in the authors' research facility a number of 167 cases were chosen consisting of both overkilling and other homicides. 70 cases were thoroughly analysed based on the completed court files, autopsy protocols and photographs. Second part of the research concerned the facts regarding the perpetrator, used weapon and the circumstances of the act. Conclusions of the conducted analysis allowed to add further characteristics to the overkilling definition: the perpetrators were almost exclusively men, around 35 of age, not related to the victim but might have been in a close relationship with them, often a conflicted one. They did not threaten the victim before the incident. Mostly perpetrators were not intoxicated, and they tried to cover up the homicide in various ways. Perpetrators of overkilling were in most cases mentally disturbed (and thus stated insane), had different levels of intelligence but also a low level of planning before the act - rarely taking actions as preparing the weapon in advance, choosing the scene or luring in the victim.

Overkilling: A specific type of homicide - Constructing the definition: Injuries and victim.

Overkilling in the Forensic Medicine field is known as a specific type of homicide where the number of inflicted injuries greatly surpasses the number of fatal ones. Conducted research aimed to create a unified definition of the phenomenon and its classification criteria by analysing a vast majority of data concerning its various characteristics. From the population of homicide victims autopsied in the authors' research facility a number of 167 cases were chosen consisting of both overkilling and other homicides. 70 cases were thoroughly analysed based on the completed court files, autopsy protocols and photographs. First part of the research concerned the facts regarding the injuries sustained and the victim's characteristics. Conclusions of the statistical analysis allowed to characterize overkilling as a type of homicide where the number of injuries (sharp or blunt) is several times higher than the number of fatal injuries. Sharp force injuries predominate, and are often localized on the torso, neck and limbs, while blunt force injuries are localized mostly on the head. There is no significant dominance between the sexes of the victims, mostly they are in their 40-50's. Victims with reduced abilities to resist predominated (mostly women), which is correlated with the position of their body (lying or sitting) at the begging of the incident. Also overkilling victims more often suffer from defensive injuries and post mortem trauma.

Restraint asphyxia. An analysis of the circumstances and mechanism of death in agitated, physically restrained individuals. / Asfiksja restrykcyjna. Analiza okolicznosci i mechanizmu smierci osób pobudzonych psychoruchowo, w trakcie obezwladniania z uzyciem sily.

Recent years saw frequent media reports of young people who die while they are being arrested by the police. Death in these circumstances affects people who are agitated and restrained with the use of force, with their autopsies indicating no unequivocally traumatic cause of death. The goal of this study was to identify the mechanism and circumstances of sudden deaths in agitated individuals who are being restrained. Ten cases evaluated at our center since 2010 were included in this study: nine involved forensic postmortem examination and one involved casefile analysis. In each case there was sudden cardiac arrest or at least a loss of consciousness, and the cardiopulmonary resuscitation proved ineffective. In six cases the cause of agitation was acute psychosis, in four it was an effect of narcotics, usually in high concentration. Conjunctival petechiae were detected in only five cases. The most probable cause of death in the evaluated cases was the combination of physical exertion caused by pathological psychomotor agitation and forcible restraint, hindering the function of the respiratory system. This mechanism is known as restraint asphyxia.

The various pathological manifestations of a lightning strike exemplified in a single four-fatality incident - A case report and review of a literature.

The lightning strike is one of leading cases of weather-related death worldwide. We present an unusual case of four fatality-lightning strike with various pathological manifestations. All victims died from a single lightning strike in the mountains that also caused injury to 156 other people. All victims had mechanical damage and rock damage that are typical for lightning strikes in the mountainside. Another lesions indicative of lightning strike and electrical damage were, among others: burnt and torn clothes (all cases) current marks (Cases 1, 2 and 3) and Lichtenberg figures along with flashover marks on Case 1. In the review we described the pathophysiological mechanisms of lightning-induced lesions and injuries and epidemiological trends of lightning-strike deaths. Our study exemplifies various manifestations of lightning strikes on forensic examination and underlines the necessity to take lightning strike into consideration when investigating open-air deaths of unclear origin.

Morphology and Position of the Right Atrioventricular Valve in Relation to Right Atrial Structures.

The right atrioventricular valve (RAV) is an important anatomical structure that prevents blood backflow from the right ventricle to the right atrium. The complex anatomy of the RAV has lowered the success rate of surgical and transcatheter procedures performed within the area. The aim of this study was to describe the morphology of the RAV and determine its spatial position in relation to selected structures of the right atrium. We examined 200 randomly selected human adult hearts. All leaflets and commissures were identified and measured. The position of the RAV was defined. Notably, 3-leaflet configurations were present in 67.0% of cases, whereas 4-leaflet configurations were present in 33.0%. Septal and mural leaflets were both significantly shorter and higher in 4-leaflet than in 3-leaflet RAVs. Significant domination of the muro-septal commissure in 3-leflet valves was noted. The supero-septal commissure was the most stable point within RAV circumference. In 3-leaflet valves, the muro-septal commissure was placed within the cavo-tricuspid isthmus area in 52.2% of cases, followed by the right atrial appendage vestibule region (20.9%). In 4-leaflet RAVs, the infero-septal commissure was located predominantly in the cavo-tricuspid isthmus area and infero-mural commissure was always located within the right atrial appendage vestibule region. The RAV is a highly variable structure. The supero-septal part of the RAV is the least variable component, whereas the infero-mural is the most variable. The number of detected RAV leaflets significantly influences the relative position of individual valve components in relation to right atrial structures.

Mutual Arrangements of Coronary Blood Vessels within the Right Atrial Appendage Vestibule.

BACKGROUND: The aim of our study was to investigate the presence and mutual relationships of coronary vessels within the right atrial appendage (RAA) vestibule. METHODS: We examined 200 autopsied hearts. The RAA vestibule was cross-sectioned along its isthmuses (superior, middle, and inferior). RESULTS: The right coronary artery (RCA) was present in 100% of the superior RAA isthmuses but absent in 2.0% of hearts within the middle isthmus and in 6.5% of hearts within the inferior RAA isthmus. Its diameter was quite uniform along the superior (2.6 ± 0.8 mm), middle (2.9 ± 1.1 mm), and inferior (2.7 ± 0.9 mm) isthmuses (p = 0.12). The location of the RCA varied significantly, and it was sometimes accompanied by other accessory coronary vessels. In all the isthmuses, the RCA ran significantly closer to the endocardial surface than to the epicardial surface (p < 0.001). At the superior RAA isthmus, the artery was furthest from the right atrial endocardial surface and this distance gradually decreased between the middle RAA isthmus and the inferior RAA. CONCLUSIONS: This study was the most complex analysis of the mutual arrangements and morphometric characteristics of coronary blood vessels within the RAA vestibule. Awareness of additional blood vessels within the vestibule can help clinicians plan and perform safe and efficacious procedures in this region.

[Modus operandi of insane offenders in multiple homicides]. / Modus operandi niepoczytalnych sprawców w zabójstwach wielokrotnych.

Homicides committed by insane offenders have been rarely investigated from the forensic point of view in a comprehensive and detailed manner. The objective of the study was to describe and characterize the modus operandi and personal characteristics in cases when more than one victim was killed and the perpetrator was deemed insane in judicial proceedings. Differences between single and multiple-vitim homicides in the population of insane murderers were also examined. Complete dossiers and forensic examination reports of 21 homicide victims killed by 9 individuals were retrospectively analyzed. The comparative control group consisted of 41 cases with only one victim killed by a single insane perpetrator. The offence and offender variables were subjected to a comparative statistical analysis. The results indicated some specific factors that can be regarded as distinctive features more commonly observed in multiple vs. single victim killings perpetrated by insane individuals. There was a significant correlation between, psychosis with depressive delusions, emotional/affective motivation, common domicile and a positive relationship between the perpetrator and the victim, infanticide committed in the perpetrator's offspring, actions with elements of planning, attacking victims while asleep, attacking from the back rather than from the front, concentration and clustering of injuries in one region of the body and multiple psychotic homicides. The results and conclusions of this study can provide practical, useful implications for homicide investigations, offender profiling or forensic psychiatric and psychological evidence.