Redefining the Post-Mortem Investigation of Sudden Cardiac Death: Systematic Cardiac MR with Macroscopic and Histological Correlation from the Friuli Venezia Giulia Regional Registry

Figures

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  Figure 1. T2- (A) and T1-weighted (B) short-axis cardiac images showing preserved signal intensity despite proximal occlusion of the left anterior descending (LAD) coronary artery. Gross pathological (C) and histological (D) analyses revealed an ischemic area in the posterior region with inflammatory infiltrate; findings consistent with hyperacute ischemic injury undetectable in T1- and T2-weighted images acquired (20×).

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  Figure 2. T2-weighted PM-CMR images of a formalin-fixed heart showing hypointense striae (arrows), consistent with hypostasis (A,B).

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  Figure 3. Formalin-fixed heart from a 49-year-old woman who died of cardiac arrest due to myocardial infarction. PM-CMR shows a hypointense subendocardial crescent-shaped lesion in the posterolateral wall of the left ventricle on fat-suppressed T2-weighted image (A), with a corresponding hypointense signal surrounded by a hyperintense rim on fat-suppressed T1-weighted images (B). T2 and T2* mapping demonstrate reduced values within the ischemic core, consistent with haemorrhagic infiltration (C,D). Histological examination confirms the presence of widespread interstitial haemorrhagic components (10×) (E).

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  Figure 4. Formalin-fixed heart from a 50-year-old man who died during physical activity. PM-CMR shows an extensive crescent-shaped intramural hypointense area within the mid interventricular septum on fat-suppressed Dixon T1-weighted (A) and iso- to slightly hyperintense signal on T2-weighted images (B). T1 mapping (C) demonstrates increased values consistent with fibrotic tissue, subsequently confirmed by histological examination (10×) (D), the myocardial fibrosis is also macroscopically visible ((E), white arrows).

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  Figure 5. Sudden cardiac death of a 45-year-old man with a family history of not investigated sudden death (both parents), found dead at home. PM-CMR of explanted and fixed in formalin heart showed extensive fatty infiltration of the infero-medio-basal wall of the left ventricle on T1-weighted Dixon with and without fat suppression images (A,B), confirmed by autopsy and histological findings (10×), demonstrating adipose metaplasia and severe coronary atherosclerosis (C,D).

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  Figure 6. Sudden cardiac death in a 48-year-old man. PM-CMR of a formalin-fixed explanted heart showing an atheromatous plaque (arrows) of the left main coronary artery on T1-weighted (A) and T2-weighted (B) images. Section of formalin-fixed explanted heart showing the same atheromatous plaque of the left main coronary artery (C). Histological sections of an atheromatous plaque from the same explanted heart are shown in (D) (4×).

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  Figure 7. Sudden cardiac death in a 23-year-old man found lifeless at home. PM-CMR of a formalin-fixed heart with hypertrophic cardiomyopathy, marked septal hypertrophy on four-chamber long-axis (A) and short-axis T1 (B). After dissection of the heart, hypertrophy of left ventricle walls and interventricular septum were confirmed (C). Myocardium disarray, hypertophic myocites and focal interstitial fibrosis completed histological panel of findings (20×) (D).

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  Figure 8. Diagnostic algorithm for the investigation of sudden death in individuals aged <50 years potentially eligible for inclusion in the Friuli Venezia Giulia Regional Registry of Sudden Cardiac Death in the Young. MRI, magnetic resonance imaging.