Etiology of pure tricuspid regurgitation based on anular circumference and leaflet area: analysis of 45 necropsy patients with clinical and morphologic evidence of pure tricuspid regurgitation.

Despite recent renewed interest in the detection of tricuspid valve regurgitation by echocardiographic and Doppler techniques, little morphologic information is available on dysfunctioning tricuspid valves. This report describes 45 necropsy patients with clinical and morphologic evidence of pure (no element of stenosis) tricuspid regurgitation and provides morphometric observations (anular circumference, leaflet area) of the tricuspid valve useful in determining the etiology of pure tricuspid regurgitation. Of 45 patients, 24 (53%) had pure tricuspid regurgitation resulting from an anatomically abnormal valve (prolapse in 7, papillary muscle dysfunction in 6, rheumatic disease in 5, Ebstein's anomaly in 3, infective endocarditis in 2, carcinoid tumor in 1), and 21 (47%) had an anatomically normal valve with systolic pulmonary artery hypertension (cor pulmonale in 12, mitral stenosis in 9). Anular circumference was dilated (greater than 12 cm) in patients with various causes of pulmonary hypertension, floppy valve and Ebstein's tricuspid anomaly. Leaflet area was increased in floppy valve and Ebstein's anomaly. Of the 45 patients, 24 had pulmonary systolic artery pressure measurements available for correlation with tricuspid valve morphology. Pulmonary artery pressures accurately predicted morphologically normal from abnormal valves in 16 patients (89%). Morphologic overlap occurred in six patients with pulmonary pressures of 41 to 54 mm Hg. Of these six, the additional knowledge of normal or dilated anular circumference correctly separated valves with normal and abnormal leaflets.

Hypoplastic coronary arteries and high takeoff position of the right coronary ostium. A fatal combination of congenital coronary artery anomalies in an amateur athlete.

This report describes a previously unrecognized combination of congenital coronary artery abnormalities in the heart of a 30-year-old amateur athlete who died suddenly during a basketball game. Both right and left circumflex coronary arteries were half of their normal length (hypoplastic) decreasing posterior ventricular myocardial perfusion. In addition, the right coronary ostium rose 5 mm above the sinotubular junction (high takeoff position), which also contributed to decreased right coronary artery perfusion. This combination of congenital coronary arterial lesions should be added to the list of structural cardiac defects associated with exercise-related sudden death.

Rupture of the left ventricular free wall following mitral valve replacement for mitral stenosis: a cause of complete (fatal) or contained (false aneurysm) cardiac rupture.

Complete or incomplete left ventricular free wall rupture is a known complication of mitral valve replacement. Complete free wall rupture may result in fatal bleeding, whereas incomplete rupture may result in the formation of a pseudoaneurysm with survival possible. Two necropsy patients are described illustrating both of these complications. Proposed mechanisms for injury to the left ventricular free wall are reviewed.

Cardiac pathology in 2007 consecutive forensic autopsies.

The incidence of various types of cardiovascular disease was evaluated in 2007 consecutive forensic patients. Cardiovascular deaths accounted for 22.8% of the study patients and atherosclerotic coronary heart disease was the most common type of cardiac disease (18%). Among subjects dying of atherosclerotic coronary disease, sudden death was three times more frequent than acute myocardial infarction. Expected cardiac findings included the incidence of severe coronary atherosclerosis (21%), floppy mitral valves (5%), and congenital bicuspid aortic valves (1%). Major cardiac findings occurred in 32% and minor cardiac findings were found in 40%. Only 17% of hearts were anatomically normal. An unexpected cardiac necropsy finding included the high frequency of myocardial bridges (23%). Unexpected cardiac findings included the low incidence of acute myocarditis (0.6%) and common finding of tunneled epicardial coronary arteries ("myocardial bridges") (23%).

Incidence of sudden athletic deaths between 1985 and 1990 in Marion County, Indiana.

Relatively little information is available concerning the incidence of sudden death in athletes in the United States. The present study provides annual incidence rates of sudden athletic deaths in Marion County, Indiana, home of Indianapolis, the "amateur sports capital of the world." The overall incidence was 0.04% (18 athletic deaths in 44,481 forensic necropsies). This incidence varied slightly over the 6-year study period: 1985 (0.06%), 1986 (0.03%), 1987 (0.04%), 1988 (0.09%), 1989 (0%), 1990 (0.01%). Of the 18 sudden athletic deaths, 88% were cardiac in origin. A retrospective analysis of preparticipation screening efforts suggests that most of the cardiac conditions responsible for death could have been detected.

Fatalities involving bicycles: a non-random population.

Bicycle riders constitute a small subgroup of all roadway deaths. Bicycle/motor vehicle collision fatalities are less frequent than pedestrian/motor vehicle fatalities. Studies have shown that non-fatal injuries of bicyclists are not randomly distributed, but follow age and sex trends that differ in the U.S. and Scandinavia. Although the bicycle-related fatalities reviewed herein do not constitute a complete profile of all such cases within our geographic area, review of these cases does provide insight into the non-random population of fatally injured cyclists in urban and rural America. A retrospective demographic and forensic medical review of 36 bicycle-related fatalities was done to clarify features of this non-random population. Consistent features including age and sex, patterned injuries and risk-taking behavior are discussed. Three of 24 (12%) adult cyclists died of homicidal gunshot wounds.

Disinterment from paving materials: use of heavy equipment for exhumation and examination of bodies.

Common paving materials--concrete and asphalt--pose an unusual and complex barrier to disinterment and examination of human remains. Although not commonly encountered, these materials are seen with sufficient frequency to justify consideration of the procedures and equipment necessary for disinterment. Over a seven year period we have encountered paving materials seven times. In each of these cases, the material was slightly different in quality, and different tools--including heavy construction equipment--were necessary. Sometimes the paving material could be managed without heavy power tools, but occasionally specialized construction tools have proven very useful.

Cardiac injury during valve replacement surgery.

The commonly referenced mortality of cardiac valve replacement surgery is 2 to 5%. Some of this mortality is due to therapeutic misadventure during the procedure. Therapeutic misadventure during cardiac valve replacement may result in patterned injury of the heart, so that postmortem examination can establish the nature of the surgical injury. A case of patterned myocardial injury during valve replacement surgery is presented, with a review of literature and associated cases.

Homicidal cardiac lacerations in children.

We report six cases of intentionally inflicted cardiac laceration. The victims ranged in age from 9 weeks to 2 1/2 years. Five victims were girls and in five cases the right atrium was lacerated. The left ventricle was lacerated in the other case. In the three cases with a confession, one victim each was struck with a fist, stomped, and kicked. Four patients had rib fractures, with at least two fractures in each case. Cardiac rupture from blunt trauma most commonly results from compression of the heart between the sternum and vertebral column, but may also occur from compression of the abdomen or legs, deceleration, blast injury, puncture of the heart by a fractured rib, and rupture through a resolving contusion. Accidentally acquired cardiac lacerations usually result from motor vehicle accidents or similarly severe forces. In children there are neither well documented cases of cardiac laceration nor of rib fractures from cardiopulmonary resuscitation. Cardiac lacerations, as with other types of severe trauma acquired at home, are almost never accidental.

Concealment of the body in drug deaths.

Discovery of a concealed body often leads to the assumption that the manner of death was homicide. However, in cases where death has resulted from illicit drug use or drug abuse, the body may be concealed to protect persons involved in drug abuse or drug marketing.

Identification of a red "fiber": chironomid larvae.

During preliminary examination of the body of a homicide victim, a peculiar red "fiber" was noticed and recovered. Initially believing this to be a carpet fiber, the item was subjected to fiber analysis. It was found to be a short coiled particle not like any known natural or synthetic fabric fiber. Subsequent examinations determined this "fiber" to be the larva of a common freshwater midge (Diptera; Chironomidae). Chironomid larvae have been observed on other bodies recovered from freshwater environments. Entomological studies of this organism have led to the conclusion that the presence of chironomid larvae indicates submersion of the body.

Use of aquatic insects in determining submersion interval.

Although its potential is great, the use of aquatic insects in determining submersion intervals at death-scene investigations has not been exploited in the past. Aquatic environments have no known true specific indicator species, as do terrestrial habitats. However, aquatic environmental studies show that organisms may colonize a substrate dependent on factors such as size, position, exposure to current, water temperature, current speed, water depth, the presence of algal communities, or detritus. Certain aquatic insects such as the chironomid midges (Diptera, Chironomidae), and the caddisflies (Trichoptera), are capable of colonizing immersed bodies; and with the known biology of a specific species of insect for a certain geographic area, time intervals of submersion can be established.

Firearm suicides during confrontations with police.

We reviewed the case records of suicides in Marion County, Indiana (Indianapolis) and in surrounding counties from 1984 through 1992. Out of 1203 suicides, there were 14 in which armed, on-duty police officers were confronting, pursuing, or apprehending the subject of the death investigation. All subjects were male, and the peak age range was 30 to 34 years. The head, especially the right temple, was the usual site of the fatal wound. More than half of the incidents started as domestic disputes with a wife or girlfriend. Many of the others occurred when police officers pursued or arrested a suspect wanted for a previous felony. Ethanol was involved in less than half of the cases, and drugs were not a factor. In at least four cases, the presence of police was a factor that precipitated the suicide. The histories of the 14 cases demonstrate the potential for controversy and the challenges for forensic scientists investigating suicides during police confrontations.

Asphyxial deaths due to hanging in children.

A review of the records for five years from the Coroner's Offices of Marion County, Indiana and Franklin County, Ohio, which have a combined population of 2.4 million, yielded 12 cases of hanging deaths in children 13 years of age or younger. The age range was 2 1/2 to 13 years and only two of the 12 victims were female. There were three unequivocal suicides, five accidental deaths and four cases where, despite extensive investigation, the manner of death remained undetermined. The scene and autopsy findings are presented and the cases discussed with regard to determination of manner of death. Additionally, the significance and pathophysiology of petechiae are discussed.

Investigation of the 1987 Indianapolis Airport Ramada Inn incident.

On October 20, 1987, a military reserve aircraft lost power during a transcontinental flight and attempted an emergency landing at The Indianapolis International Airport. The pilot ejected and the disabled and pilotless aircraft struck a bank building. It then skidded across the street and entered the lobby of The Airport Ramada Inn where it exploded. This incident was unusual in that the fatal injuries occurred in individuals on the ground and not in the occupant of the aircraft. Seven people were killed in the lobby area and two were trapped in a laundry where they died of smoke inhalation. A tenth person died of burns ten days later. Minor injuries were reported among four hotel guests, two firefighters and the Air Force pilot. A multiagency mass disaster-plan had been formulated and rehearsed in preparation for the Panamerican Games, which had been held in Indianapolis in August 1987. A number of volunteers arrived before a security perimeter was established. They began an undocumented removal of the bodies from the scene and were about to remove valuables for "safekeeping" when stopped by coroners' office personnel. Fatalities resulted from smoke inhalation, burns or a combination. Bodies were identified by a combination of dental records, personal effects and visual means within 24 hours. The problems encountered in managing this disaster scene will also be compared with previously reported incidents.

Fatal and near-fatal animal bite injuries.

Fatal and near-fatal maulings of humans by pit bulls have recently become a topic of major public concern, resulting in the passage of laws in some jurisdictions that make the owner of a pit bull criminally liable for manslaughter if his or her pet causes a human death. The authors recently investigated two cases in which children were fatally injured by pet dogs. In the first case, a 17-day-old girl suffered fatal abdominal injuries when attacked by a pregnant Siberian husky. A 2-year-old girl expired from neck wounds inflicted by a pit bull or a rottweiler or both. Because no expert would testify as to which dog caused the fatal injury, the owner of the animals was not charged under a statute which specified criminality only if a pit bull caused the fatal injury. We also examined a 12-year-old boy who attempted to pet a circus tiger; the animal grabbed his arm with its claws and bit off the arm at the shoulder. The arm could not be reattached, but the child survived. These cases and the differentiation of animal bites from other injuries will be presented.

Fatal anorectal injuries: a series of four cases.

Anorectal injuries associated with sexual practices have become more frequently reported in the last decade. Although anorectal injuries are commonly reported in cases of sexual abuse of children, fatalities are very rare. In this series of cases, we report a case of fatal child abuse resulting from anal intercourse. In addition, there are two cases of death in females as a result of heterosexual "fisting" or "handballing." The fourth case of the series is that of a homicidal injury produced by rectal impalement with a 31 inch length of threaded pipe.

Cardiac pathology in 470 consecutive forensic autopsies.

Cardiovascular disease continues to be the single most common generic cause of sudden and unexpected deaths. Atherosclerotic coronary heart disease and acute myocardial infarction are the most prevalent forms of fatal cardiac disease observed at autopsy. Other cardiac lesions are frequently listed as causes of death, but the prevalence of such lesions as incidental findings in the general population is unknown. In this study, 470 consecutive forensic autopsies were evaluated for minor and major anomalies. The most frequently observed major congenital finding was floppy mitral valve (5%). Tunneled coronary arteries, considered minor congenital findings, were seen in 29%. Atherosclerotic coronary heart disease was the most common major acquired finding, observed in 16% of cases. Of the 470 hearts, only 8% were considered normal.

Giant ventral hernias and their repair. A 10 year follow up study.

A consecutive series of 32 repairs of massive incisional hernias have been followed up for a median of 45 months (range 8 months to 11 years). The reconstruction was based on the frontal leaf of the rectus abdominis and insertion of free fascia or pedicle flap from the tensor fascia lata muscle combined with transposition of the rectus muscle. Median size of the hernias was 20 x 17 cm (range 6-35 x 8-30). The incidence of risk factors for both recurrence as well as operative complications was high. During the median observation period of 45 months 9 hernias recurred, the main benefit of a successful reconstruction was relief of pain in the abdominal wall and the lower back. We conclude that the method is useful for the treatment of patients with large ventral hernias. Reduction of controllable recurrence risk factors is important, and the treatment requires substantial resources and expertise.