This study highlights SCD during psychological stress, mostly in young males where the sudden death occurred in the absence of structural heart disease. This may reflect the proarrhythmic potential of high catecholamines on the structurally normal heart in those genetically predisposed because of cardiac channelopathy. Structural cardiomyopathies and coronary artery disease also feature prominently. Cases of SCD associated with altercation and restraint receive mass media attention especially when police/other governmental bodies are involved. This study highlights the rare but important risk of SCD associated with psychological stress and restraint in morphologically normal hearts and the importance of an expert cardiac opinion where prolonged criminal investigations and medico-legal issues often ensue.

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We present a case of a young man with Duchenne muscular dystrophy cardiomyopathy (DMDC) having an implantable cardioverter defibrillator for secondary prevention, who presented with electrical storm shortly after β-blocker interruption. The patient was stabilized and remained free of ventricular arrhythmias soon after reinitiating b-adrenoreceptor antagonists. The present case highlights the importance of sympathetic blockage in patients with DMDC due to existing pathophysiology of excess diastolic Ca leak from sarcoplasmic reticulum as a result of ryanodine receptor dysfunction.

Background: Radiofrequency (RF) ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is occasionally complicated with atrioventricular block (AVB) often predicted by junctional beats (JB) with loss of ventriculo-atrial (VA) conduction. Methods:We analyzed retrospectively 153 patients undergoing ablation of SP for typical AVNRT. Results:The A(H)-A(RFd) and A(RFd)-A(CS) intervals were significantly shorter in RF applications causing JB than those without JB (33 ± 11 ms vs 39 ± 9 ms, P < 0.001, 14 ± 9 ms vs 20 ± 7 ms, P < 0.001, respectively). The A(H)-A(RFd) and A(RFd)-A(CS) intervals were also significantly shorter in RFs causing JB with VA block than those with VA conduction (29 ± 11 ms vs 35 ± 11 ms, P < 0.001, 8 ± 8 ms vs 17 ± 8 ms, P < 0.001, respectively). Patients > 70 years had shorter intervals (36 ± 11 ms vs 29 ± 8 ms, P = 0.012, 17 ± 8 ms vs 13 ± 7 ms, P = 0.027, respectively), while VA block was more common in this age group.

Background In forensic practice, a blow to the chest can lead to sudden cardiac death (SCD). Commotio cordis and contusio cordis are leading causes. Methods From a database of 4678 patients who suffered from SCD, we found three patients with commotio cordis and two patients with contusio cordis. All the patients were examined macroscopically and microscopically and had negative toxicology screen. Results The three patients who died due to commotio cordis were young males (16, 23 and 38 years old). The circumstances of death were: a blow to the chest by a football, by a friend during a party and during an assault. The hearts were completely normal at autopsy. The two patients who had contusio cordis were older males (42 and 63 years old). Both patients died during traffic accidents. At autopsy, one had significant contusion over the left ventricle, and the second had contusion over the right ventricle. Conclusion This study indicates that a blow to the chest is very important to document in the circumstances of death, and a detailed history is vital. It raises the left ventricular intra-cavitary pressure, leading to commotio cordis with immediate death with a normal heart. Blunt chest trauma can cause direct myocardial lesions, with acute changes leading to contusio cordis.

prevalence of low flow and its accompanying vascular functional parameters after successful aortic valve replacement (AVR). Aim of the study and methods We set out to assess the prevalence of low flow as well as of abnormal valvulo-aortic impedance and systemic arterial compliance following AVR. We recruited unselected, consecutive patients attending our echocardiography laboratory who had interpretable echo images and LF ejection fraction >! 50%. We calculated aortic valve area (AVA) by continuity equation; stroke volume indexed to body surface area (SVi = LVOT VTI x LVOT Area ; units --ml/ m 2 ; normal >35 ml/m 2 ) valvulo-aortic impedance Zva = (MPG+SBP)/SVi); units --mmHg/ml/m 2 ; normal <5 mmHg/ ml/m 2 where MPG is mean pressure gradient, SBP is systolic blood pressure and systemic arterial compliance (ml/mm Hg/ m 2 ) SAC = SVi/Pulse pressure), normal <£ 0.6. Results We studied 77 patients with AVR, 49 male, mean age (SD) 68 (7.8) years. The mean AVA (SD) was 1.59 (0.59) cm 2 ; mean Zva (SD) was 5.02 (0.58); mean SVi (SD) was 30.6 (9.6); mean SAC was 0.48 (0.18). AVA was <1 cm 2 in 11 (14%) patients with AVA, 1-1.5 cm 2 in 24 (32%) and >1.5 cm 2 in 424 (55%). SVi was low in 57 (74%), Zva was elevated in 37 (48%), and SAC was elevated in 16 (21%) of patients. A higher proportion of patients had abnormal SVi, Zva and SAC amongst those with AVA<1.5 cm 2 than in those with AVA >1.5 cm 2 . Conclusion A significant proportion of patients have abnormal valvulo-aortic loads, low-flow states, and abnormal arterial compliance after successful aortic valve replacement. Further study is warranted to assess the potential clinical significance of these findings.

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