Regressive Changes of the Myocardial Sleeves in Elderly Victims of Sudden Bathtub Death
Affiliation(s)
Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Japan.
Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Japan.
ABSTRACT
In Japan, most sudden deaths occurring during bathing happen in the winter, and predominantly to elderly people. One can infer a relation to physical conditions that are specific to aging. Atrial fibrillation, an arrhythmia, increases with age. This study examined histological changes in the pulmonary vein myocardial sleeves of sudden bathtub death victims and compared them with those of control individuals. We investigated 35 sudden deaths that occurred during bathing and 34 accidental deaths or deaths caused by diseases unrelated to cardiopathies. Pulmonary veins were excised cross-sectionally from the hilar side to the venoatrial junction. Then they were stained with hematoxylin and eosin, resorcin-fuchsin van Gieson, and Congo-red stains. Amyloid deposits in the pulmonary vein myocardial sleeves, as well as the range and severity of scarring, were graded microscopically on a scale of 0-3. In the sudden bathtub death victims, severe scarring was found in the myocardial sleeves of the four pulmonary veins (mean score, 2.0), which was significantly different (p < 0.05) from the control subjects (mean score, 1.4). Cardiomegaly was found in 28 out of the autopsied individuals. In subjects with cardiomegaly, the mean value of pulmonary vein myocardial sleeve scarring was 2.1. In subjects without cardiomegaly, the mean value was 1.8. Comparison revealed that cardiomegaly was associated significantly with scarring progression and degeneration of the myocardial sleeves. Scarring of the pulmonary vein myocardial sleeves was more advanced in victims of sudden bathtub death than in controls without heart disease. Elderly people with scarring of the pulmonary vein myocardial sleeves are likely to develop degenerative variations in their intra-atrial excitation conduction. These results demonstrate that taking hot baths might induce supraventricular arrhythmias such as atrial fibrillation.
In Japan, most sudden deaths occurring during bathing happen in the winter, and predominantly to elderly people. One can infer a relation to physical conditions that are specific to aging. Atrial fibrillation, an arrhythmia, increases with age. This study examined histological changes in the pulmonary vein myocardial sleeves of sudden bathtub death victims and compared them with those of control individuals. We investigated 35 sudden deaths that occurred during bathing and 34 accidental deaths or deaths caused by diseases unrelated to cardiopathies. Pulmonary veins were excised cross-sectionally from the hilar side to the venoatrial junction. Then they were stained with hematoxylin and eosin, resorcin-fuchsin van Gieson, and Congo-red stains. Amyloid deposits in the pulmonary vein myocardial sleeves, as well as the range and severity of scarring, were graded microscopically on a scale of 0-3. In the sudden bathtub death victims, severe scarring was found in the myocardial sleeves of the four pulmonary veins (mean score, 2.0), which was significantly different (p < 0.05) from the control subjects (mean score, 1.4). Cardiomegaly was found in 28 out of the autopsied individuals. In subjects with cardiomegaly, the mean value of pulmonary vein myocardial sleeve scarring was 2.1. In subjects without cardiomegaly, the mean value was 1.8. Comparison revealed that cardiomegaly was associated significantly with scarring progression and degeneration of the myocardial sleeves. Scarring of the pulmonary vein myocardial sleeves was more advanced in victims of sudden bathtub death than in controls without heart disease. Elderly people with scarring of the pulmonary vein myocardial sleeves are likely to develop degenerative variations in their intra-atrial excitation conduction. These results demonstrate that taking hot baths might induce supraventricular arrhythmias such as atrial fibrillation.
KEYWORDS
Sudden Bathtub Death, Autopsy, Pulmonary Veins, Myocardial Sleeves, Atrial Fibrillation, Scarring
Sudden Bathtub Death, Autopsy, Pulmonary Veins, Myocardial Sleeves, Atrial Fibrillation, Scarring
Cite this paper
Satoh, F. , Seto, Y. , Tsuboi, A. and Osawa, M. (2015) Regressive Changes of the Myocardial Sleeves in Elderly Victims of Sudden Bathtub Death. Forensic Medicine and Anatomy Research, 3, 57-65. doi: 10.4236/fmar.2015.32011.
Satoh, F. , Seto, Y. , Tsuboi, A. and Osawa, M. (2015) Regressive Changes of the Myocardial Sleeves in Elderly Victims of Sudden Bathtub Death. Forensic Medicine and Anatomy Research, 3, 57-65. doi: 10.4236/fmar.2015.32011.
References
[1] Satoh, F., Osawa, M., Hasegawa, I., Seto, Y. and Tsuboi, A. (2013) “Dead in Hot Bathtub” Phenomenon. Accidental Drowning or Natural Disease? American Journal of Forensic Medicine and Pathology, 34, 164-168. http://dx.doi.org/10.1097/PAF.0b013e31828d68c7 [2] Chiba, T., Yamauchi, M., Nishida, N., Kaneko, T., Yoshizaki, K. and Yoshioka, N. (2005) Risk Factors of Sudden Death in the Japanese Hot Bath in the Senior Population. Forensic Science International, 149, 151-158. http://dx.doi.org/10.1016/j.forsciint.2004.04.085 [3] Benjamin, E.J., Wolf, P.A., D’Agostino, R.B., Silbershatz, H., Kannel, W.B. and Levy, D. (1998) Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study. Circulation, 98, 946-952.
http://dx.doi.org/10.1161/01.CIR.98.10.946 [4] Lloyd-Jones, D.M., Wang, T.J., Leip, E.P., Larson, M.G., Levy, D., Vasan, R.S., D’Agostino, R.B., Massaro, J.M., Beiser, A., Wolf, P.A. and Benjamin, E.J. (2004) Lifetime Risk for Development of Atrial Fibrillation: The Framingham Heart Study. Circulation, 110, 1042-1046.
http://dx.doi.org/10.1161/01.CIR.0000140263.20897.42 [5] Haissaguerre, M., Jaïs, P., Shah, D.C., Takahashi, A., Hocini, M., Quiniou, G., Garrigue, S., Le Mouroux, A., Le Métayer, P. and Clémenty, J. (1998) Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins. New England Journal of Medicine, 339, 659-666.
http://dx.doi.org/10.1056/NEJM199809033391003 [6] Haissaguerre, M., Jaïs, P., Shah, D.C., Arentz, T., Kalusche, D., Takahashi, A., Garrigue, S., Hocini, M., Peng, J.T. and Clémenty, J. (2000) Catheter Ablation of Chronic Atrial Fibrillation Targeting the Reinitiating Triggers. Journal of Cardiovascular Electrophysiology, 11, 2-10.
http://dx.doi.org/10.1111/j.1540-8167.2000.tb00727.x [7] Steiner, I., Hájková, P., Kvasnicka, J. and Kholová, I. (2006) Myocardial Sleeves of Pulmonary Veins and Atrial Fibrillation: A Postmortem Histopathological Study of 100 Subjects. Virchows Archiv, 449, 88-95.
http://dx.doi.org/10.1007/s00428-006-0197-2 [8] Fynn, S.P. and Kalman, J.M. (2004) Pulmonary Veins: Anatomy, Electrophysiology, Tachycardia, and Fibrillation. Pacing and Clinical Electrophysiology, 27, 1547-1559.
http://dx.doi.org/10.1111/j.1540-8159.2004.00675.x [9] Hsieh, M.H., Tai, C.T., Tsai, C.F., Yu, W.C., Lee, S.H., Lin, Y.K., Ding, Y.A., Chang, M.S. and Chen, S.A. (2000) Pulmonary Vein Electrogram Characteristics in Patients with Focal Sources of Paroxysmal Atrial Fibrillation. Journal of Cardiovascular Electrophysiology, 11, 953-959.
http://dx.doi.org/10.1111/j.1540-8167.2000.tb00166.x [10] Saito, T., Waki, K. and Becker, A.E. (2000) Left Atrial Myocardial Extension onto Pulmonary Veins in Humans: Anatomic Observations Relevant for Atrial Arrhythmias. Journal of Cardiovascular Electrophysiology, 11, 888-894. http://dx.doi.org/10.1111/j.1540-8167.2000.tb00068.x [11] Hitosugi, M., Takatsu, A., Kinugasa, Y. and Takao, H. (1999) Estimation of Normal Heart Weight in Japanese Subjects: Development of a Simplified Normal Heart Weight Scale. Legal Medicine, 1, 80-85.
http://dx.doi.org/10.1016/S1344-6223(99)80017-0 [12] Yoshioka, N. (2008) Sudden Death in the Japanese Hot Bath in the Senior Population. Journal of the Japanese Society of Balneology, Climatology and Physical Medicine, 72, 31-35. [13] Shigeomi, S., Sato, W., Enzan, K. and Yoshioka, N. (2001) Sudden Death during Bathing in the Elderly. JJAAM, 12, 109-120. http://dx.doi.org/10.3893/jjaam.12.109 [14] Schuessler, R.B., Grayson, T.M., Bromberg, B.I., Cox, J.L. and Boineau, J.P. (1992) Cholinergically Medicated Tachyarrhythmias Induced by a Single Extra Stimulus in the Isolated Canine Right Atrium. Circulation Research, 71, 1254-1267. http://dx.doi.org/10.1161/01.RES.71.5.1254 [15] Wijffels, M.C., Kirchhof, C.J., Dorland, R. and Allessie, M.A. (1995) Atrial Fibrillation Begets Atrial Fibrillation. A Study in Awake Chronically Instrumented Goats. Circulation, 92, 1954-1968.
http://dx.doi.org/10.1161/01.CIR.92.7.1954 [16] Nattel, S. and Li, D. (2000) Ionic Remodeling in the Heart: Pathophysiological Significance and New Therapeutic Opportunities for Atrial Fibrillation. Circulation Research, 87, 440-447.
http://dx.doi.org/10.1161/01.RES.87.6.440 [17] Yue, L., Feng, J., Gaspo, R., Li, G.R., Wang, Z. and Nattel, S. (1997) Ionic Remodeling Underlying Action Potential Changes in a Canine Model of Atrial Fibrillation. Circulation Research, 81, 512-525.
http://dx.doi.org/10.1161/01.RES.81.4.512 [18] Wu, T.J., Yashima, M., Xie, F., Athill, C.A., Kim, Y.H., Fishbein, M.C., Qu, Z., Garfinkel, A., Weiss, J.N., Karagueuzian, H.S. and Chen, P.S. (1998) Role of Pectinate Muscle Bundles in the Generation and Maintenance of Intra-Atrial Reentry: Potential Implications for the Mechanism of Conversion between Atrial Fibrillation and Atrial Flutter. Circulation Research, 83, 448-462.
http://dx.doi.org/10.1161/01.RES.83.4.448
[1] Satoh, F., Osawa, M., Hasegawa, I., Seto, Y. and Tsuboi, A. (2013) “Dead in Hot Bathtub” Phenomenon. Accidental Drowning or Natural Disease? American Journal of Forensic Medicine and Pathology, 34, 164-168. http://dx.doi.org/10.1097/PAF.0b013e31828d68c7 [2] Chiba, T., Yamauchi, M., Nishida, N., Kaneko, T., Yoshizaki, K. and Yoshioka, N. (2005) Risk Factors of Sudden Death in the Japanese Hot Bath in the Senior Population. Forensic Science International, 149, 151-158. http://dx.doi.org/10.1016/j.forsciint.2004.04.085 [3] Benjamin, E.J., Wolf, P.A., D’Agostino, R.B., Silbershatz, H., Kannel, W.B. and Levy, D. (1998) Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study. Circulation, 98, 946-952.
http://dx.doi.org/10.1161/01.CIR.98.10.946 [4] Lloyd-Jones, D.M., Wang, T.J., Leip, E.P., Larson, M.G., Levy, D., Vasan, R.S., D’Agostino, R.B., Massaro, J.M., Beiser, A., Wolf, P.A. and Benjamin, E.J. (2004) Lifetime Risk for Development of Atrial Fibrillation: The Framingham Heart Study. Circulation, 110, 1042-1046.
http://dx.doi.org/10.1161/01.CIR.0000140263.20897.42 [5] Haissaguerre, M., Jaïs, P., Shah, D.C., Takahashi, A., Hocini, M., Quiniou, G., Garrigue, S., Le Mouroux, A., Le Métayer, P. and Clémenty, J. (1998) Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins. New England Journal of Medicine, 339, 659-666.
http://dx.doi.org/10.1056/NEJM199809033391003 [6] Haissaguerre, M., Jaïs, P., Shah, D.C., Arentz, T., Kalusche, D., Takahashi, A., Garrigue, S., Hocini, M., Peng, J.T. and Clémenty, J. (2000) Catheter Ablation of Chronic Atrial Fibrillation Targeting the Reinitiating Triggers. Journal of Cardiovascular Electrophysiology, 11, 2-10.
http://dx.doi.org/10.1111/j.1540-8167.2000.tb00727.x [7] Steiner, I., Hájková, P., Kvasnicka, J. and Kholová, I. (2006) Myocardial Sleeves of Pulmonary Veins and Atrial Fibrillation: A Postmortem Histopathological Study of 100 Subjects. Virchows Archiv, 449, 88-95.
http://dx.doi.org/10.1007/s00428-006-0197-2 [8] Fynn, S.P. and Kalman, J.M. (2004) Pulmonary Veins: Anatomy, Electrophysiology, Tachycardia, and Fibrillation. Pacing and Clinical Electrophysiology, 27, 1547-1559.
http://dx.doi.org/10.1111/j.1540-8159.2004.00675.x [9] Hsieh, M.H., Tai, C.T., Tsai, C.F., Yu, W.C., Lee, S.H., Lin, Y.K., Ding, Y.A., Chang, M.S. and Chen, S.A. (2000) Pulmonary Vein Electrogram Characteristics in Patients with Focal Sources of Paroxysmal Atrial Fibrillation. Journal of Cardiovascular Electrophysiology, 11, 953-959.
http://dx.doi.org/10.1111/j.1540-8167.2000.tb00166.x [10] Saito, T., Waki, K. and Becker, A.E. (2000) Left Atrial Myocardial Extension onto Pulmonary Veins in Humans: Anatomic Observations Relevant for Atrial Arrhythmias. Journal of Cardiovascular Electrophysiology, 11, 888-894. http://dx.doi.org/10.1111/j.1540-8167.2000.tb00068.x [11] Hitosugi, M., Takatsu, A., Kinugasa, Y. and Takao, H. (1999) Estimation of Normal Heart Weight in Japanese Subjects: Development of a Simplified Normal Heart Weight Scale. Legal Medicine, 1, 80-85.
http://dx.doi.org/10.1016/S1344-6223(99)80017-0 [12] Yoshioka, N. (2008) Sudden Death in the Japanese Hot Bath in the Senior Population. Journal of the Japanese Society of Balneology, Climatology and Physical Medicine, 72, 31-35. [13] Shigeomi, S., Sato, W., Enzan, K. and Yoshioka, N. (2001) Sudden Death during Bathing in the Elderly. JJAAM, 12, 109-120. http://dx.doi.org/10.3893/jjaam.12.109 [14] Schuessler, R.B., Grayson, T.M., Bromberg, B.I., Cox, J.L. and Boineau, J.P. (1992) Cholinergically Medicated Tachyarrhythmias Induced by a Single Extra Stimulus in the Isolated Canine Right Atrium. Circulation Research, 71, 1254-1267. http://dx.doi.org/10.1161/01.RES.71.5.1254 [15] Wijffels, M.C., Kirchhof, C.J., Dorland, R. and Allessie, M.A. (1995) Atrial Fibrillation Begets Atrial Fibrillation. A Study in Awake Chronically Instrumented Goats. Circulation, 92, 1954-1968.
http://dx.doi.org/10.1161/01.CIR.92.7.1954 [16] Nattel, S. and Li, D. (2000) Ionic Remodeling in the Heart: Pathophysiological Significance and New Therapeutic Opportunities for Atrial Fibrillation. Circulation Research, 87, 440-447.
http://dx.doi.org/10.1161/01.RES.87.6.440 [17] Yue, L., Feng, J., Gaspo, R., Li, G.R., Wang, Z. and Nattel, S. (1997) Ionic Remodeling Underlying Action Potential Changes in a Canine Model of Atrial Fibrillation. Circulation Research, 81, 512-525.
http://dx.doi.org/10.1161/01.RES.81.4.512 [18] Wu, T.J., Yashima, M., Xie, F., Athill, C.A., Kim, Y.H., Fishbein, M.C., Qu, Z., Garfinkel, A., Weiss, J.N., Karagueuzian, H.S. and Chen, P.S. (1998) Role of Pectinate Muscle Bundles in the Generation and Maintenance of Intra-Atrial Reentry: Potential Implications for the Mechanism of Conversion between Atrial Fibrillation and Atrial Flutter. Circulation Research, 83, 448-462.
http://dx.doi.org/10.1161/01.RES.83.4.448