15283-B-Blokker

171 General discussion 9 of the body, 99 using a modified heart-lung machine, 264 or target mainly the coronary arteries. 118,120,127,133,165,261-263 The latter approach is cheaper and requires less training than the former. Both angiography methods are time consuming and may invoke difficulties for the differentiation between technique-related or post-mortem artefacts and true pathological findings. 128,152 A common difficulty within the cardiovascular system is distinguishing post-mortem clotting from true emboli, especially in the right side of the heart and the pulmonary arteries. 59,108,109,265 With PMCT-angiography this clotting may even be mistaken for a dissection 266 or a fat embolism. 267 For this latter diagnosis and, generally, for any diagnosis of pulmonary thromboembolism, the radiological images have to be combined with targeted biopsies from the suspected clots. 108,109,265,267 Besides the detection of occluded vessels, PMCT-angiography appears to improve soft tissue imaging, 265 and it helps to identify bleeding as the cause of death, 268 even small branches may be identified as bleeding source. 265 The attitude of next-of-kin towards PMCT-angiography seems positive. 89 In our cohort, MIA missed one myocardial infarction and in only one case the cardiac findings were misinterpreted (acute myocardial ischemia versus ischemia secondary to abscesses in the heart). This is a significant improvement compared to our pilot study, 57 which is mainly due to the application of multiple CT-guided biopsies from different regions of the myocardium, partially directed by the positive MRI findings, whereas in the pilot a few biopsies of the heart were taken under ultrasound-guidance or even without guidance. In another case the biopsy findings were suspicious for bilateral peripheral pulmonary emboli, but the diagnosis was not certain at MIA. As a pilot study within our cohort, we explored the feasibility of post-mortem CT- angiography for the visualization of the coronary arteries, targeted via the left carotid artery. However, we planned not to use this technique in every case, for it would be too time consuming and expensive. Only in those cases with a possible cardiac cause of death and no other obvious cause of death present at the unenhanced MRI and CT scans we performed the CT-angiography to further examine the coronary arteries. Using this criterion, we needed angiography in a quarter of the study population. We mainly experienced difficulties with the cannulation of the carotid artery in cases of obesity; difficulties with positioning and inflating the balloon of the catheter correctly, and occluding the ascending aorta but not the openings of the coronaries; and difficulties with the interpretation of the images, especially if the contrast did not reach the distal parts of the coronary arteries or if there had been surgical interventions in the past (e.g. bypass surgery, or valve replacement).