Pathology cases — postpartum left anterior coronary artery dissection

This is a case of a young adult woman who gave birth to a healthy term infant about two weeks before death.  Her husband noted that she was seizing one night in bed, and then collapsed.  At autopsy, she was generally healthy.  There was a little bit of necrotic retained placenta still in the uterus, but nothing else of note.  I didn’t notice much on the LAD grossly, but when I grabbed a section along with the anterior left ventricle, as I have a habit of doing, to my surprise, there was a small dissection there.  Close examination of the myocardium revealed acute and subacute microinfarctions.

In forensic pathology, we are specifically concerned with discovering causes of sudden death — prolonged illnesses do not become Medical Examiner cases for the most part.  The heart, lungs, and brain are the high value targets for investigation, and in relatively young people without obvious gross lesions, the heart is number one in my experience.  Accordingly, I take lots of sections of the heart for histologic evaluation in these cases.  Normally, I take a section from each quadrant of the left ventricle (counting the IVS as left ventricle), one section from the right ventricle, a couple of slices through the sinoatrial node, and a section around the atrioventricular node.  The atrioventricular node section is particularly valuable to me, but I’ll talk about that in a different post.

Here’s a section of the distal left anterior descending coronary artery in this case:

Here’s one of the small infarctions:

Postpartum coronary artery dissection is rare, but remains the most common cause of dissection in young adults.

As always, free for use in lecture, or teaching, with or without attribution (though attribution is appreciated).  If you put these in a publication, please contact me.  Higher resolution images (8Kx5K pixels) are available on request until I lose them, if you need them for a lecture or such.  Email me if you want me to send them to you.