Multidisciplinary Medico-Legal Death Investigation

Role of Consultants

Lakshmanan Sathyavagiswaran,Christopher B. Rogers

• Publisher: Academic Press
• Year: 2018
• ISBN:
  9780128138199
• Topic: Diritto
• Subtopic: Scienza forense

Multidisciplinary Medico-legal Death Investigation: Role of Consultants is the only book in the field that focuses on the role consultants have in medical examiner/coroner offices. The book provides a multidisciplinary view on the topic by including specialized fields, such as anesthesiology, surgery, radiology, including CT scan, pediatrics, cardiology-electrophysiology, cardiac pathology, forensic anthropology and odontology, firearms examination, firearms, eye pathology and psychiatry/psychology. Coverage also includes chapters on specialized topics, including high profile cases, the media, business continuity planning, envenomations, the importance of quality assurance and peer review, and quality assurance in a medico-legal death investigation office.

This one-of-a-kind resource is ideal for those in the medico-legal death investigation field and professionals in the criminal and civil justice system.

• Covers many fields, including anesthesiology, surgery, and radiology, including CT scan, pediatrics, cardiology-electrophysiology, cardiac pathology, forensic anthropology and odontology, firearms examination, and more
• Includes contributions by world-renowned specialists
• Presents comprehensive case studies and examples of consultation reports

Chapter 1

Role of the Cardiac Electrophysiology Consultant

Noel G. Boyle, MD, PhD, FACC, FRCPI, FRCP¹, Christopher Rogers, MD, MBA² and Lakshmanan Sathyavagiswaran, MD, FRCP(C), FACP, FCAP³, ¹UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, CA, United States, ²Los Angeles County Department of Medical Examiner-Coroner, Los Angeles, CA, United States, ³Los Angeles County Chief Medical Examiner-Coroner/Director (Retired), Los Angeles, CA, United States

Abstract

Cardiac pacemakers are common medical devices used to treat symptomatic bradycardias and implantable cardioverter defibrillators are routinely used in the treatment of ventricular tachyarrhythmias and in prevention of sudden cardiac death. Both these cardiac implantable electronic devices are now commonly found at autopsy, and interrogation of these devices may yield valuable information in decedent identification, and in the time and mode of death, to augment the information available to the forensic pathologist. We review the current state of the literature in the field and discuss examples from the archives of the Los Angeles County Coroner’s office. New devices for pacing and defibrillation, in addition to new arrhythmia and heart failure monitoring devices, are discussed.

Keywords

Pacemaker; defibrillator; ICD; autopsy; safety; forensic pathology

Introduction

In the period from 1993 to 2006, 2.4 million people received pacemakers and a further 0.8 million implantable cardioverter defibrillators (ICDs) in the United States, so these devices are now commonly encountered by the pathologist at autopsy (Kurtz et al., 2010; Saint-Martin et al., 2008). Since the first pacemaker implantation in 1958, and the first ICD implantation in 1981, there has been a rapid technological development in these devices with smaller and more programmable devices which can now store large amounts of information about the patient and their cardiac rhythm history. While in most cases the device information and interrogation may not be relevant to the questions arising at autopsy, in selected cases, it may provide critical information to the forensic pathologist in identifying the patient and the time and mode of death.

The earliest discussions of pacemaker evaluation from the postmortem standpoint of the pathologist were from Raasch in the 1970s (Raasch, 1977, 1978). He advocated that the pathologist “examine the pacemaker and its lead as an integral part of an autopsy.” He posed three questions to be addressed: Was there a signal? Was it effective? Could anything have altered it? In a 1974 analysis of deaths in pacemaker patients, Siddons found that 9 of 145 deaths in patients with pacemakers were related to pacemaker malfunctions, with failure to pace in six and “speeding pacemaker” in three; however, this study predates the advent of stored electrograms and modern highly reliable pacemakers.

Advances in pacemaker and ICD battery and lead technology in recent decades now mean that device failure is a very rare finding, particularly for pacemakers, although occasionally it still occurs with ICDs (Guidant device). However, lead function in ICDs remains an Achilles heel of even modern ICD devices (Fidelis, Riata leads).

Pacemakers

Pacemakers are implanted for clinically symptomatic bradycardias, either due to sinus or atrioventricular node dysfunction. Patients who have intrinsic (underlying) heart rates <30 bpm are termed pacemaker dependent, and could experience loss of consciousness (syncope) or even death should the pacemaker fail. This could be due to malfunction of the device itself, battery depletion, or lead malfunction. Modern devices are well shielded and rarely influenced by external electromagnetic signals.

The systematic assessment of the value of interrogating pacemakers postmortem was first outlined by Raasch (1977). In this report, he discusses the approach to pacemakers at autopsy, and in evaluating 56 consecutive cases from the office of the San Diego County Coroner, found no generator output in two cases and a lead defect in one. It is important to remember that in this era, devices had virtually no programmability or electrogram storage and the rate was changed by a needle-like wrench inserted through the skin and rotated. One of the first uses of an implanted pacemaker to identify a decedent was reported by Sathyavagiswaran and colleagues in 1992, when they described how a patient found down in the street who later died in hospital was identified by means of information stored in his implanted pacemaker device, when no fingerprint or dental identification was possible. More recently, following the tsunami disaster of March 2011 in Japan, forensic pathologists used pacemaker programmers to scan 148 unidentified remains, found one victim with an implanted pacemaker and were able to get a full identification from the pacemaker interrogation (Makinae et al., 2013). Mond and colleagues (2002) reported the use of pacemaker interrogation in a murder victim to identify events leading to death—sinus tachycardia during assault, atrial, and ventricular pacing during unconscious period and terminal ventricular fibrillation (VF)—providing a valuable time stamp on the events prior to death.

In the largest postmortem study of pacemakers from deceased patients, conducted by Bartsch and co-workers (2005) at three German centers from 2001 to 2002, 415 pacemakers were evaluated. Life-threatening abnormalities were found in 3.8%, potentially life threatening in 3.7%, premature exhaustion in 1.2%, and lead-related issues in 16.1%. In the life-threatening category, there were two defective pacemakers, seven battery exhaustions, one ventricular lead failure, one infection, and one unipolar lead programmed for bipolar sensing. Of note the mean age of patients at implant was 80.7 years, with an average survival of 4 years after implant.

In a report of 20 cases of cardiac implantable electronic devices (CIEDs) from the office of the Los Angeles County Coroner published in 2008 from our group, Saint-Martin reported on 13 pacemaker cases. In 3 of the pacemaker cases from this series, the device was able to identify the time and mode of death [ventricular tachycardia (VT)] in a decedent found in decomposition in an apartment, the identity of an unknown patient found down in the street who died of coronary artery disease, and the cause of death as battery depletion in a third pacemaker-dependent patient who died in a motor vehicle accident. In one of the seven ICDs evaluated, device interrogation confirmed VT which resulted in syncope and head trauma as the cause of death. An example of a pacemaker with battery depletion is shown in Fig. 1.1. A pacemaker interrogation showing VT in a stored electrogram recorded at the time of death is depicted in Fig. 1.2.

Figure 1.1 Pacemaker interrogation report indicating that battery was depleted. Reproduced from Saint-Martin, P., Rogers, C., Muto, J., Boyle, N.G., Rieders, D., Sathyavagiswaran, L., 2008. Pacemaker/defibrillator evaluation at Los Angeles County Department of Coroner. J. Forensic Sci. 53(5), 1160–1165.

Figure 1.2 Pacemaker log interrogation showing episode of VT, with date and time of event corresponding with patient’s demise. Reproduced from Saint-Martin, P., Rogers, C., Muto, J., Boyle, N.G., Rieders, D., Sathyavagiswaran, L., 2008. Pacemaker/defibrillator evaluation at Los Angeles County Department of Coroner. J. Forensic Sci. 53(5), 1160–1165.

Kirkpatrick and colleagues (2007) surveyed morticians in Chicago and Philadelphia on device interrogation and explanation practices. The average number of devices explanted annually by morticians was 7±10 (range 1–50). Only 4% of morticians routinely returned devices to manufacturer for interrogation, and an additional 4% were returned to the implanting hospital; the majority (44%) were disposed of as medical waste. In a European study from Germany and Spain, also reported in 2007, Nägele and c...