title: Sudden, unexpected death in cardiac transplant recipients: an autopsy study.
abstract: BACKGROUND
  Clinical studies indicate that sudden death (SD) is common after heart transplantation. Autopsy reports of such patients are sparse.
  
  
  METHODS
  We performed a retrospective study of clinical and pathologic findings on all autopsied patients who underwent heart transplantation at our institution from January 1984 to July 2002.
  
  
  RESULTS
  There were 74 patients who survived >2 months. Of these, 28 (37.8%) died suddenly. The major causes of sudden death (SD) included acute cellular rejection (ACR) (n = 11, 39.3%) and graft coronary artery disease (GCAD) (n = 11, 39.3%). In 9 patients (32.1%), there was no anatomic cause of death. These deaths, assumed to be primary arrhythmic death (PAD), occurred 5 to 36 months post-transplantation. Pre-transplant diagnosis of idiopathic dilated cardiomyopathy (IDCM) was more common in SD (13 of 28, 46.4% vs 9 of 46, 19.6%; p = 0.014). Hypertrophy was not statistically different in SD vs non-SD (79.4% vs 88.4%; p = 0.38). Coronary thrombosis was also not statistically different in sudden GCAD deaths vs non-sudden GCAD deaths (3 of 11, 27.3% vs 8 of 13, 61.5%; p = 0.09). ACR SD patients had fewer episodes of ACR in biopsies than ACR non-SD patients (93 of 190, 48.9% vs 99 of 159, 63.3%; p = 0.01). Biopsies with Quilty lesions (QL) were more frequent in patients with SD (206 of 461, 44.7% vs 243 of 710, 34.2%; p < 0.001). QL were more common in patients with GCAD (44.4%) and ACR (39.6%) than in patients who died of infection (25.7%; P < 0.001 and p < 0.01, respectively).
  
  
  CONCLUSIONS
  SD after cardiac transplantation is common (37.8% of all deaths). ACR, in the first year, and GCAD, afterwards, are associated with SD. PAD occurred in 32.1% of SD cases, 5 to 36 months after transplantation. Pre-transplant diagnoses of IDCM and QL are more common in SD. Surprisingly, cardiac hypertrophy is not increased and coronary thrombosis is not more frequent in patients who died suddenly.
authors.affiliation: Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
authors.forename: Chavit
authors.initials: C
authors.lastname: Chantranuwat
authors.forename: John D
authors.initials: JD
authors.lastname: Blakey
authors.forename: Jon A
authors.initials: JA
authors.lastname: Kobashigawa
authors.forename: Jaime D
authors.initials: JD
authors.lastname: Moriguchi
authors.forename: Hillel
authors.initials: H
authors.lastname: Laks
authors.forename: Maria Espejo
authors.initials: ME
authors.lastname: Vassilakis
authors.forename: Michael C
authors.initials: MC
authors.lastname: Fishbein
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000150:complications*; D001344:Autopsy; D002648:Child; D002675:Child, Preschool; D003324:Coronary Artery Disease / Q000150:complications*; D003645:Death, Sudden / Q000209:etiology* / Q000473:pathology*; D005260:Female; D006084:Graft Rejection / Q000150:complications*; D016027:Heart Transplantation / Q000009:adverse effects*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors