Morphologic Markers of Acute and Chronic Stress in Child Abuse.

OBJECTIVES: To elucidate pathologic markers of acute and chronic stress found but rarely reported in chronic child abuse. METHODS: Autopsies of 3 cases of fatal child abuse with well-documented chronic maltreatment are reported, with an emphasis on the nontraumatic findings of acute and chronic stress. RESULTS: Besides the overwhelming physical injuries, all 3 children and 1 additional case obtained for consultation had telogen effluvium, a form of alopecia well known to be associated with stress in adults and some children but never reported in chronic abuse. All 3 had the microscopic findings of markedly involuted thymus, a well-known marker of physiologic stress in children but only occasionally referred to in child abuse. All 3 also had microscopic findings of myocardial necrosis associated with supraphysiologic levels of catecholamine, a well-documented finding associated with stress but rarely reported in fatalities associated with child abuse. Two of the 3 children also had Anitschkow-like nuclear changes in cardiac tissue, markers associated with prior, nonischemic myocardial pathologies that may be associated with prior episodes of acute stress. CONCLUSIONS: Pathologists are urged to explore these markers as supportive evidence in their own investigations of possible child abuse fatalities, especially when associated with stress.

Morphologic Markers of Acute and Chronic Stress in Child Abuse.

OBJECTIVES: To elucidate pathologic markers of acute and chronic stress found but rarely reported in chronic child abuse. METHODS: Autopsies of 3 cases of fatal child abuse with well-documented chronic maltreatment are reported, with an emphasis on the nontraumatic findings of acute and chronic stress. RESULTS: Besides the overwhelming physical injuries, all 3 children and 1 additional case obtained for consultation had telogen effluvium, a form of alopecia well known to be associated with stress in adults and some children but never reported in chronic abuse. All 3 had the microscopic findings of markedly involuted thymus, a well-known marker of physiologic stress in children but only occasionally referred to in child abuse. All 3 also had microscopic findings of myocardial necrosis associated with supraphysiologic levels of catecholamine, a well-documented finding associated with stress but rarely reported in fatalities associated with child abuse. Two of the 3 children also had Anitschkow-like nuclear changes in cardiac tissue, markers associated with prior, nonischemic myocardial pathologies that may be associated with prior episodes of acute stress. CONCLUSIONS: Pathologists are urged to explore these markers as supportive evidence in their own investigations of possible child abuse fatalities, especially when associated with stress.

Left ventricular noncompaction cardiomyopathy in end-stage heart failure patients undergoing orthotopic heart transplantation.

BACKGROUND: Previous studies reported that left ventricular noncompaction (LVNC) is a cardiomyopathy, familial or sporadic, arising from arrest of the normal process of trabecular remodeling during embryonic development. The diagnosis is usually made by echocardiography, but to date, there has been little research on the occurrence and clinicopathological features of LVNC in the explanted hearts of orthotopic heart transplant (OHT) recipients. DESIGN: The clinical, echocardiographic, and pathologic findings were reviewed for evidence of LVNC, diagnosed by echocardiographic criteria, in 105 patients with end-stage heart failure (HF) undergoing OHT. Analyses of multiple sections of the explanted hearts were carried out. The hearts were evaluated for grades (0, negative; 1, mild/occasional foci; 2, moderate/multiple foci; 3, severe/extensive, diffuse) of fibrosis, reactive and replacement, hypertrophy, myocytolysis in left ventricle, right ventricle, interventricular septum, and atria. Absolute measurements of noncompacted and compacted portions of the left ventricle wall and noncompacted/compacted ratios were calculated. RESULTS: Isolated LVNC was observed in 0 of 54 ischemic cardiomyopathy and in 4 of 51 (7.8%) nonischemic cardiomyopathy patients - 2 men and 2 women, with a mean age±SEM of 34.2±6.9years. The echocardiogram disclosed marked left ventricular dilatation, prominent trabeculations, and left ventricle ejection fraction <20%. Mural thrombi were seen in 3 of 4 (75%) patients. The heart weight mean±SEM was 468±55.3 g (range, 340-600g); noncompacted myocardium was 22±5.8mm, compacted myocardium was 13.2±3.5mm, and noncompacted/compacted ratio was 1.7/1±0.2. The total scores of hypetrophy, myocytolysis, and fibrosis were as follows: left ventricle, 7.7±0.2; right ventricle, 6.2±0.5; interventricular septum, 6.7±0.2; and atria, 7.5±0.3. CONCLUSIONS: LVNC is an unusual form of nonischemic cardiomyopathy in patients suffering from end-stage HF undergoing OHT. The variability in the noncompacted/compacted ratio and discordance between the echocardiographic and pathological findings points to the need for further clarification of diagnostic imaging and diagnostic criteria for LVNC. Further studies in larger series, correlating the anatomoclinical and genetic variables, also would improve our understanding of LVNC as a cause of advanced HF leading to OHT.

Clinical and histological predictive risk factors of atrial fibrillation in patients undergoing open-heart surgery.

Postoperative atrial fibrillation (POAF) is a common complication subsequent to cardiac surgery. Various risk factors have been reported for the development of this complication; however, their precise role in POAF is unknown. In the present study, we attempted to identify clinical factors and histopathological changes in atrial tissue that may predict the development of POAF. Atrial tissue was sampled from 103 patients in sinus rhythm that had undergone open-heart surgery, including elective coronary artery bypass grafting (79.61%) and heart valve surgery (20.38%). Atrial surgical biopsies were obtained from the right atrial appendage at the site of cannulation, prior to cardiopulmonary bypass. Tissues were processed routinely for light microscopy, then stained with hematoxylin and eosin and sirius red. Microscopical exams were used to observe the atrial lesions and morphometry was conducted for quantification. In total, 37 patients (35.92%) developed POAF and atrial lesions were identified in the majority of patients in the normal postoperative sinus rhythm and POAF groups, but were most common in the POAF patients. The most common risk factors involved in developing POAF were found to be: Age of >60 years, male gender, ejection fraction of <50% and increased pulmonary hypertension. Furthermore, interstitial fibrosis and myocytolysis were the most common injuries identified. Abnormalities in atrial surgical biopsies may indicate the susceptibility of a patient to developing POAF. The present results suggest that the pre-existent alterations in the structure of the right atrium may be a major determinant in the development of POAF.

Pathological assessment of end-stage heart failure in explanted hearts in correlation with hemodynamics in patients undergoing orthotopic heart transplantation.

BACKGROUND: To date, there has been little research, if any, on the pathological correlates of end-stage heart failure in the explanted hearts of orthotopic heart transplant (OHT) recipients in correlation with the patients' hemodynamics. We sought to compare the gross and histopathological parameters in hearts explanted-native or previously transplanted-from patients with end-stage heart failure with the clinical hemodynamics parameters at the time of OHT. METHODS: Forty patients undergoing OHT were enrolled in this study and divided into two groups according to whether they suffered from ischemic (ICMP) or nonischemic cardiomyopathy (NICMP). All study patients were treated with OHT for end-stage heart failure at The University of Texas Health Science Center at Houston. The pathological investigations of the hearts were focused on the study of the underlying cause of heart failure leading the patient to OHT; on the quantification of the extent and severity of fibrosis, hypertrophy, and myocytolysis; and on validating a semiquantitative grading scale. Analyses of multiple sections of the explanted hearts were carried out. The heart weights were recorded and compared with the grades of fibrosis, hypertrophy of cardiomyocytes, and myocytolysis. The grades of fibrosis, hypertrophy, and myocytolysis were evaluated in right and left ventricles and atria (with areas of confluent infarction excluded). The pathological parameters were correlated with the patients' clinical parameters. RESULTS: Twenty-two patients (20 men, 2 women, mean age±S.E.M., 62.3±2.2 years) suffered from ICMP and 18 patients (9 men, 9 women, mean age±S.E.M., 56.3±2.8 years) from NICMP. All the clinical and pathological measured variables were comparable between the two groups, except for pulmonary vascular resistance, which was higher in the NICMP group of patients, and the grade of myocytolysis, which was significantly higher in the ICMP vs. NICMP group. Most of the clinical and pathological variables were overall linearly correlated. CONCLUSIONS: Both ICMP and NICMP groups of end-stage heart failure requiring OHT presented high grades of fibrosis, hypertrophy, and myocytolysis. Heart failure is the final common pathway of a variety of primary cardiovascular diseases regardless of the ischemic or nonischemic nature of the cardiomyopathy.