A case of a death caused by an atrial-oesophageal-thoracic fistula after radiofrequency ablation of atrial fibrillation.

The report is about a 49-year-old man with rheumatic heart disease and atrial fibrillation. He underwent mitral valve replacement, tricuspid valvuloplasty, and atrial fibrillation radiofrequency ablation in the hospital. He vomited blood on the 2nd postoperative day, and the bleeding gradually worsened thereafter. He had to have repeated drainage of large amounts of blood from his right thoracic cavity and digestive tract. He died suddenly after undergoing an oesophageal endoscopy on the 24th postoperative day. The autopsy revealed an atrial-oesophageal-thoracic fistula. By excluding the possibility of the fistula being caused by complications from nasoenteric feeding, tracheal intubation, and a foreign body ingestion, we determined that the atrial-oesophageal-thoracic fistula was a complication after radiofrequency ablation according to the finding of coagulation necrosis of the myocardial cells at the left atrium fistula. In addition, we also performed an elemental analysis on the radiofrequency ablation area and other cardiac tissues by scanning electron microscopy-energy dispersive spectroscopy (SEM-EDS) and found five metal elements, Cr, Cu, Zn, Mn, and Ti, which specifically existed in the radiofrequency ablation area. This finding has the potential to serve as new evidence for radiofrequency ablation and is a worthy direction of research.

Serum atrial natriuretic peptide (ANP) as an objective indicator for the diagnosis of neurogenic shock: animal experiment and human case report.

In forensic medicine, the diagnosis of death due to neurogenic shock is considered to be an aporia, as lacking objective indicators and presenting atypical symptoms in autopsy. Medico-legal disputes and complaints occasionally result from this ambiguity. To explore potential objective indicators of neurogenic shock, we set up a model of neurogenic shock by applying an external mechanical force on the carotid sinus baroreceptor in rabbits. The serum atrial natriuretic peptide (ANP) level was measured by radioimmunoassay in the control group (n = 8), survival group (n = 15) and death group (n = 5) both before and after the insult. The serum ANP level showed a significant increase after the insult in the death group compared with the serum obtained before the insult (P = 0.006), while the serum ANP level after the insult in the survival group and control group was not statistically significant compared with the serum obtained before the insult (P = 0.332 and P = 0.492, respectively). To verify the repeatability of the model and the postmortem behavior of serum ANP, five healthy adult rabbits underwent the same procedure as the experimental group. The mortality rate was consistent with the former experiment (20 %). There were no significant changes in serum ANP level in vitro and in vivo (within 48 and 24 h, respectively). But there was a significant decrease in serum ANP level at 48 h postmortem in vivo (P = 0.001). A female patient who expired due to neurogenic shock during a hysteroscopy was reported. Neither fatal primary disease nor evidence for mechanical injuries or intoxication was found according to the autopsy. The serum ANP level was assayed as a supplementary indicator and was found to be three-fold higher than the normal maximum limit. Combined with the animal experiment, this case highlights that serum ANP has the potential to be an objective indicator for the diagnosis of death due to neurogenic shock.