Long-Term Follow-Up After Ablation of Intra-Atrial Re-Entrant Tachycardia in Patients With Congenital Heart Disease: Types and Predictors of Recurrence.

OBJECTIVES: The aim of this study was to analyze the long-term outcomes after intra-atrial re-entrant tachycardia (IART) ablation in congenital heart disease (CHD). BACKGROUND: IART increases morbidity and mortality in CHD patients. Radiofrequency catheter ablation has evolved into the first-line treatment of this complication. METHODS: This was a prospective, single-center study of all consecutive CHD patients who underwent first ablation for IART from January 2009 to December 2015 (n = 94, 39.4% female, age 36.55 ± 14.9 years, follow-up 44.45 ± 22.7 months). RESULTS: During the study period, 130 procedures were performed (n = 94, 1.21 ± 0.41 IART/patient). In the first procedure, 114 IART were ablated (short-term success 74.66%). Forty-nine percent of the patients whose IART was ablated had non-cavotricuspid isthmus (CTI)-related IART (alone or with concomitant CTI IART). After the first ablation, 54.3% maintained sinus rhythm (SR), 23.9% presented with recurrence of the ablated IART, 14.2% developed new IART, and 7.6% presented with atrial fibrillation (AF). After the second radiofrequency catheter ablation, 78.3% were in SR, 8.7% presented with AF, and 23.0% presented with IART (50% new IART). Multivariate predictors of recurrences were non-CTI IART (hazard ratio [HR]: 5.06; 95% confidence interval [CI]: 1.6 to 15.9; p = 0.006), PR interval >200 ms (HR: 4.02; 95% CI: 1.9 to 11.3; p = 0.009), AF induction (HR: 3.11; 95% CI: 1.1 to 9.1; p = 0.04). and previous AF (HR: 3.08; 95% CI: 1.1 to 9.3; p = 0.04). A risk score according multivariate model identified 3 levels of recurrence risk: 5.8%, 20%, and 58.5% (area under the receiver-operating characteristic curve 0.8 ± 0.03; p < 0.0001). CONCLUSIONS: Ablation of IART in CHD is a challenging procedure, but after ablation in experienced centers, SR can be maintained in 78.3%. Predictors of recurrences are non-CTI-related IART, long PR interval, and previous or induced AF. A risk score based on these factors can be useful for recurrence prediction.

18F-FDG-PET/CT angiography in the diagnosis of infective endocarditis and cardiac device infection in adult patients with congenital heart disease and prosthetic material.

OBJECTIVES: Infective endocarditis (IE) and cardiac device infection (CDI) are a major complication in the growing number of patients with congenital heart disease (CHD) reaching adulthood. We aimed to evaluate the added value of 18F-FDG-PET/CT angiography (PET/CTA) in the diagnosis of IE-CDI in adults with CHD and intravascular or intracardiac prosthetic material, in whom echocardiography (ECHO) and modified Duke Criteria (DC) have limitations because of the patients' complex anatomy. METHODS: A prospective study was conducted in a referral center with multidisciplinary IE and CHD Units. PET/CTA and ECHO findings were compared in consecutive adult (≥18years) patients with CHD who have prosthetic material and suspected IE-CDI. The initial diagnosis using the DC and the diagnosis with the additional PET/CTA data (DC+PET/CTA) were compared with the final diagnostic consensus established by an expert team at three months. RESULTS: Between November-2012 and April-2017, 25 patients (15 men; median age 40years) were included. Cases were initially classified as definite in 8 (32%), possible in 14 (56%) and rejected in 3 (12%). DC+PET/CTA allowed reclassification of 12/14 (86%) cases initially identified as possible IE. The sensitivity, specificity, PPV, NPV, and accuracy of DC at IE suspicion were 39.1%/83.3%/90.4%/25.5%/61.2%, respectively. The diagnostic performance increased significantly with addition of PET/CTA data: 87%/83.3%/95.4%/61.5%/85.1%, respectively. PET/CTA also provided an alternative diagnosis in 3 patients with rejected IE, and detected pulmonary embolisms in 3 patients. CONCLUSIONS: PET/CTA was a useful diagnostic tool in the complex group of adult patients with CHD who have cardiac or intravascular prosthetic material and suspected IE or CDI, providing added diagnostic value to the modified DC (increased sensitivity) and improving case classification.

Diagnóstico diferencial entre especies durante un levantamiento de dos cerebros. ¿Es fácil? ¿Es suficiente con un examen macroscópico? / Differential diagnosis of species during a recovery of two brains. Is it easy? Is a gross examination enough?

En un levantamiento nos podemos encontrar que debamos pronunciarnos sobre el origen humano o de otro tipo de animal de una víscera. Presentamos un caso inusual en el que se encontraron dos cerebros en el baño de una hamburguesería. Establecimos un diagnóstico diferencial, en atención a su peso, entre un cerebro de recién nacido o lactante menor de 6 meses y un cerebro de origen animal. La impresión inicial fue que se trataba de dos cerebros de animales, probablemente de vaca, y las pruebas complementarias analíticas confirmaron el diagnóstico. No es suficiente con una impresión de diagnóstico genérico de origen animal ante un cerebro en mal estado. Este diagnóstico tiene que ser certero y argumentado. Incluso patólogos y veterinarios de dilatada experiencia se muestran cautos a la hora de pronunciarse al respecto (AU)

At a recovery of viscera, we need to know the differences between human or another animal origin. We are presenting an unusual case where two brains were found into a burger bar toilet. Considering brain’s weight, a differential diagnosis between the brain of a newborn, a baby less than 6 months old, and an animal brain was made. The initial diagnosis was that both were animal brains, probably from a cow, and this hypothesis was later confirmed by laboratory analysis. Gross examination and the hasty conclusion that it is not human are insufficient when dealing with a brain in bad state. In this case the diagnosis must be highly accurate and thoroughly justified. Even experienced pathologists or veterinarians are cautious about these diagnosis (AU)

Cardiac complications during pregnancy are better predicted with the modified WHO risk score.

BACKGROUND/OBJECTIVE: Several risk scores (RSs) have been used to stratify risk of cardiac complications (CCs) in pregnant patients with heart disease. We aimed to compare and contrast the accuracy of several RSs for predicting CC in this population. METHODS: Prospective inclusion of all consecutive pregnant patients with heart disease, and follow-up until 6 months postpartum. CCs were defined as primary if admission was required due to heart failure, arrhythmia or thromboembolic events, and secondary if the decline in NYHA class compared with baseline was >2 or urgent invasive cardiac procedures were needed. The discriminatory power of each RS was assessed by the area-under-the receiver-operating characteristic (ROC) curve (AUC). RESULTS: 179 patients, mean age: 32 years, accounted for 13.4% of CC (primary 11.7%, secondary 1.7%); the main diagnosis was congenital heart disease (CHD) in 68% followed by valvulopathies in 16%, arrhythmia in 7% and myocardiopathies in 5%. 22% (n=40) were classified as mWHO=1, 59% (n=105) mWHO=2 including subgroup 2-3, 14% (n=26) mWHO=3 and 4%(n=7) mWHO=4; 1 patient was unclassifiable. mWHO showed a better AUC (0.763) than CARPREG (0.67). For the CHD population, ZAHARA RS showed an AUC of 0.74, and Khairy an AUC of 0.632. CONCLUSIONS: mWHO was better at predicting CC than CARPREG; mWHO was also better at predicting CC than the specific CHD RS in the CHD subgroup. PRACTICE: There are an increasing number of pregnant women with HD. IMPLICATIONS: Improved prediction of CC risk during pregnancy can provide better preconception assessment in women with HD.

Cambios morfológicos secundarios a material de sutura quirúrgica / Morphological changes due to surgical suture material

Los materiales de sutura pueden ocasionar alteraciones o artefactos que en ocasiones nos plantearán dudas de diagnóstico diferencial con procesos tumorales o de otra naturaleza. Durante la realización de una autopsia el patólogo puede hallar una masa localizada en un órgano, tejido o vaso, que le puede llevar a pensar en un proceso tumoral, y un estudio histopatológico sorprenderlo con el diagnostico de reacción tisular por material de sutura (AU)

Suture materials can cause changes or artefacts that can occasionally raise doubts in the differential diagnosis of tumour processes or of any other nature. During the performance of an autopsy, the forensic pathologist may find a mass in organs, tissues or vessels that may lead him to think about a tumoral process, and the histopathological diagnosis surprise him with tissue reaction caused by suture material (AU)

¿Muerte por malapraxis tras quemaduras de segundo grado en una menor de 2 años? / Death due to malpractice after second degree burns in child under 2 years of age?

Presentamos el caso de una menor de 2 años que falleció por bronquiolitis cuatro días después de sufrir unas quemaduras y haber sido visitada por tres equipos médicos de distintos centros. La denuncia por malapraxis formulada por los padres conllevó a la realización de autopsia médico-legal. Los resultados de la misma atribuyeron la causa de muerte a una bronquiolitis, por lo que se archivó la denuncia presentada contra los facultativos (AU)

We report the case of a child less than 2 years old who died of bronchiolitis four days after suffering burns and having being examined by three medical teams of different centres. The complaint for malpractice issued by their parents required a medico-legal autopsy. Its findings determined that bronchiolitis was the cause of death and, as a result, the complaint for medical malpraxis was discontinued (AU)

Armas eléctricas: ¿qué sabemos? ¿qué ignoramos? / Electronic control devices: what is known? what is unknown?

Las armas eléctricas se introdujeron como una alternativa a las armas de fuego en la policía, aunque también están siendo utilizadas fuera del marco de la ley. Mediante las descargas eléctricas que producen, se inmoviliza a la víctima como consecuencia de una contracción muscular tetánica dolorosa. La utilización de estas armas es controvertida, ya que se les han atribuido algunas muertes en custodia en Estados Unidos. Revisamos la literatura médica sobre este tema y concluimos que algunas veces pueden ser letales, y que es necesario analizar factores de riesgo potencial asociados para confirmar o descartar una verdadera relación causa-efecto en estos casos (AU)

Conducted energy devices are used as a non-lethal weapons by law enforcement personal internationally to subdue potentially violent or combative subjects. The victim is immobilized as a result of painful tetanic contraction of the muscles. However, controversy exists about these weapons, because they have been implicated in some deaths in custody in the United States. We review medical literature related on this topic and conclude that they are not always non lethal and that all potential associated factors must be analyzed to be able to confirm or disprove a true causal relationship (AU)

Mega apófisis transversa (Síndrome de Bertolotti) y defecto parcial de fusión posterior sacra como signos con valor identificativo en antropología forense / Anomalous enlargement of the transverse process (Bertolotti's Syndrome) and sacral fusion defect as identification signs in forensic anthropology

Cuando se localizan restos esqueletizados el médico forense debe determinar en primer lugar si éstos son o no humanos. En caso afirmativo, diagnosticar el sexo, ancestro geográfico, edad, altura y si existe alguna patología que permita la identificación. Presentamos un caso con interesantes variaciones óseas: mega apófisis transversa lumbar y un defecto parcial de fusión sacra (AU)

When skeletalized remains are discovered the forensic anthropologist needs to establish first if the bones are human. If so, the sex, race, age, stature, and any pathology must be established in order to make an identification of the remains, determine manner and cause of death. We are presenting a case with interesting bone variations: anomalous enlargement of the transverse process (Bertolotti's syndrome) and partial sacral fusion defect (AU)

Lesiones óseas postmortales secundarias a descarnamiento, corte con sierra, fuego y un roedor / Postmortem bone injuries due to dismemberment, saw cut, fire and a rodent

Durante unas obras de rehabilitación de un domicilio se encontraron, al extraer una bañera, unos restos óseos humanos en la base de la misma que pertenecían a una mujer joven desaparecida desde hacía 6 años. En un pequeño fragmento óseo femoral se encontraron los efectos provocados por descarnamiento, una sierra, la acción del fuego y un roedor que aportaron valiosa información a la investigación médico-forense y policial (AU)

Some human bones belonging to a young woman missing 6 years ago were found under a bath during a house restoration. A little broken femoral bone showed the effects due to dismemberment, saw cut, fire and a rodent. These findings were of great value to the medico-legal and police investigation (AU)

Lesiones múltiples por tenedor de mesa en el contexto de un homicidio / Multiple injuries by a table fork in a homicide

Las lesiones por tenedor de mesa no son frecuentes en el contexto de un homicidio ya que no son potencialmente letales. Presentamos un caso de homicidio por múltiples lesiones de arma blanca en el que también se encontraron otraslesiones características de haber sido producidas por un tenedor de mesa (AU)

Injuries by a table fork are uncommon in a homicide due to they are not potentially fatal. In this paper, a murder caused by multiple stab wounds and injuries by kitchen fork is presented (AU)

Hallazgo incidental de hiperostosis frontal interna o síndrome de Morgagni asociado a meningiomas / Incidental finding of frontal internal hyperostosis or Morgagni syndrome associated with meningiomas

La hiperostosis frontal interna consiste en un engrosamiento de la tabla interna del hueso frontal. Normalmente se encuentra en mujeres post menopáusicas. Presentamos un caso de hallazgo autópsico incidental de hiperostosis frontal interna o síndrome de Morgagni asociado a meningiomas en una mujer postmenopáusica (AU)

Hyperostosis frontalis interna is the accretion of bone on the inner table of the frontal bone. It is commonly found in post-menopausic women. We present an incidental finding of frontal internal hyperostosis or Morgagni syndrome associated with meningiomas in a post-menopausic woman (AU)

Hemoperitoneo secundario a rotura de carcinoma hepatocelular: Hallazgos de autopsia / Hemoperitoenum due to hepatocellular carcinoma. Autopsy findings

El hemoperitoneo secundario a la rotura de un carcinoma hepatocelular (CH) es una complicación poco frecuente en nuestro medio, siendo más infrecuente su hallazgo como causa de muerte en individuos no diagnosticados de CH. Presentamos el caso de una mujer de 87 años con antecedentes patológicos de hepatitis C crónica e hipertensión arterial y sin constancia de traumatismo abdominal previo, que debutó con un cuadro inespecífico de malestar general, náuseas y vómitos de varias horas de evolución, motivo por el cual se le prescribió y administró domiciliariamente metoclopramida. Falleció a las pocas horas de la atención médica, motivo por el cual se practicó la autopsia judicial. Durante la misma se evidenció un hemoperitoneo de 3.000 cc secundario a una rotura intratumoral sobre un hígado cirrótico (AU)

Hemoperitoneum secondary to rupture of hepatocellular carcinoma (CH) is a rare complication in our environment. His find, still more, is uncommon cause of death in individuals not diagnosed of CH. We report the case of a woman of 87 years-old with clinical history of chronic hepatitis C, hypertension, and abdominal trauma without evidence of prior, which debuted with a nonspecific malaise, nausea and vomiting several hours of evolution, why was prescribed and administered metoclopramide home. She died a few hours after care, which is why judicial autopsy was performed. The autopsy was shown a 3000 cc hemoperitoneum secondary to rupture intratumoral in a cirrhotic liver (AU)

Antropología forense como técnica complementaria en patología forense: A propósito de un caso / Forensic anthropology as a complementary technique in forensic pathology. Case report

La antropología forense suele limitarse al estudio de esqueletos, restos óseos, cadáveres en mal estado o en descuartizados, pero puede ser extraordinariamente útil como técnica complementaria en las autopsias convencionales en las que existan lesiones óseas. Presentamos un caso de un adolescente que sufrió una única herida por arma blanca en tórax. La esqueletización permitió evidenciar más lesiones costales de las que eran visibles durante la autopsia (AU)

Forensic anthropology usually only studies skeletons, human remains, corpses in bad condition or dismemberments, but it can also be outstandingly useful as a complementary technique in ordinary autopsies with bone injuries. The case we are presenting is about a teenager who suffered an unique incision in his chest and in whose post skeletonization more rib injuries became evident (AU)

Muerte súbita en un varón con astrocitoma no diagnosticado / Sudden death in a male due to undiagnosed astrocytoma

El diagnóstico de tumoraciones cerebrales en los servicios de patología forense es muy poco frecuente y suelen llegar a ellos ya sea como consecuencia de muertes súbitas o en el contexto de denuncias por mala praxis médica. Dentro de la escasa frecuencia, la mayoría de ellos son únicamente hallazgos incidentales de autopsia, como en el caso de muchos meningiomas, pero en otros puede ser la causa de muerte. Presentamos el caso de un varón paquistaní de 40 años, con barrera idiomática, que consultó en un servicio de urgencias por un cuadro de cefalea, náuseas y vómitos y que falleció después del alta médica con el diagnóstico de cuadro respiratorio de vías altas. La autopsia y los estudios anatomopatológicos evidenciaron un astrocitoma grado II (AU)

Brain tumors are seldom studied in forensic pathology services and they are seen in circumstances such as sudden unexpected death or in malpractice complaints. In most cases they are incidental findings, like meningioma, and in few cases they are the cause of death. We present the case of a 40 years old male Pakistani with linguistic barrier suffering from headache and vomiting who was diagnosed as a flue and died suddenly. Forensic autopsy and histopathologic studies showed a grade II astrocytoma (AU)

Agenesia de vena cava inferior en un caso de autopsia forense / Absence of the inferior cava vein in a case of forensic autopsy

La agenesia de vena cava inferior es una entidad congénita poco frecuente que a menudo se asocia con otras severas anomalías congénitas o malposiciones viscerales. También ha sido descrita como un factor de riesgo de trombosis venosa en pacientes jóvenes. La mayoría de los casos publicados proceden de estudios radiológicos y muy raramente aparece como hallazgo necrópsico. Presentamos un caso de agenesia de vena cava inferior, sin otras anomalías asociadas, que apareció como hallazgo incidental en una autopsia forense (AU)

The absence of the inferior vena cava is a rare congenital anomaly, often associated with severe congenital deformities and visceral position abnormalities. It has been described also as a risk factor for deep vein thrombosis in young patients. We present a case of congenital absence of inferior vena cava appeared as an incidental finding in a forensic autopsy (AU)

Muerte súbita en epilepsia desde el punto de vista médico forense / Sudden death in epilepsy from a medico-legal point of view

La muerte súbita-inesperada en pacientes epilépticos (MSE) es una entidad clínica que, a pesar de su frecuencia, continúa siendo bastante desconocida por los médicos en general y por los médicos forenses en particular. Al diagnóstico de MSE se llega por exclusión de otras causas de muerte por lo que es necesario una adecuada investigación médico-forense de cada caso que tenga en cuenta la revisión de los antecedentes clínicos, examen del lugar de la muerte y autopsia minuciosa incluyendo estudios complementarios toxicológicos de alcohol, drogas de abuso y niveles de fármacos anticomiciales. El resultado de la investigación médico-forense es fundamental para conocer la incidencia, características epidemiológicas y el perfil de riesgo de la MSE en nuestro medio. Con este abordaje se podrán establecer estrategias que hagan posible su prevención (AU)

Demencia con delirio: aproximación médico forense / Dementia with delusion: a medico-legal approach

La demencia con delirio, aunque relativamente frecuente en la población general, en pocas ocasiones es diagnosticada inicialmente por el médico forense en el juzgado de guardia. Presentamos un caso de demencia con delirio que fue diagnosticada en un varón de 67 años a raíz de que la esposa presentara una denuncia por maltrato conyugal en el juzgado de guardia. Revisamos además la patología psiquiátrica asociada a la demencia que puede tener interés desde el punto de vista médico forense (AU)

Obesidad, dermolipectomía, tromboembolismo pulmonar y muerte súbita. Presentación de un caso y revisión de la literatura / Obesity, dermolipectomy, pulmonary thromboembolism and sudden death. Case report and literature review

En nuestra sociedad moderna existe una crecien-te demanda de corrección quirúrgica de la silueta. Las intervenciones quirúrgicas más frecuentes para ello son la liposucción y la dermolipectomía. Existen pocos estudios sobre las muertes relacionadas con estos procedimientos. Presentamos un caso de muerte súbita en una mujer de 53 años que ocurre tras practicar una dermolipectomía abdominal por un aumento masivo de peso. La autopsia médicolegal determinó que la muerte se produjo como consecuencia de un tromboembolismo pulmonar. Revisamos las complicaciones, resultados inesperados y muerte súbita en estas técnicas quirúrgicas y la relación entre obesidad y tromboembolismo pulmonar (AU)

Chest pain during exercise as first manifestation of Friedreich's ataxia.

Cardiac function is affected in up to 90% of patients with Friedreich's ataxia, the most common spinocerebellar degenerative disease. Friedreich's ataxia typically causes motor abnormalities of the extremities, mainly impairing walking and the coordination of the legs and arms. The myocardium is affected at a later stage of the disease. The extent and timing of myocardial involvement determines the clinical course. Some patients have no cardiac symptoms and cardiac involvement can be established only by electrocardiographic or echocardiographic examination. In addition some pathological studies have found evidence of coronary abnormalities, mainly in the small vessels. There are no reports that such lesions cause angina. In a 16 year old patient chest pain on exercise had been the presenting symptom of Friedreich's ataxia at the age of 9. Considerable alterations in ventricular repolarisation on the electrocardiogram suggested a congenital coronary abnormality or hypertrophic myocardiopathy. The results of a Doppler echocardiography, Holter monitoring, and a haemodynamic study with coronary arteriography were all normal. An exercise test when the boy was 13 indicated significant changes in ventricular repolarisation. Myocardial scintigraphy (99mTc-MIBI) at that time, however, was normal. He improved slightly when he was treated with verapamil. When he was 15 neurological symptoms developed and Friedreich's ataxia was diagnosed. Typical angina during exercise seems to have been the first symptom of Friedreich's ataxia.