ORIGINAL ARTICLE

Myocardial necrosis and infarction in newborns and infants

Andrew R. Bamber • Jeremy Pryce •

Andrew Cook • Michael Ashworth •

Neil J. Sebire

Accepted: 20 June 2013

� Springer Science+Business Media New York 2013

Abstract

Purpose This study aimed to investigate the incidence,

and underlying associations, of myocardial necrosis

occurring in infants undergoing autopsy.

Methods An autopsy database containing anonymized

details of all infant autopsies conducted at Great Ormond

Street Hospital between January 1996 and December 2010

was searched to identify all infants with myocardial

necrosis. The characteristics of the necrosis and any

underlying associations were reviewed.

Results Myocardial necrosis was recorded in 187 autop-

sies out of a total of 1,637 (11.4 %), and was localized to

the papillary muscles, subendocardial region, or trabeculae

in 50.8 % of cases. The most common associations were

congenital heart disease, perinatal asphyxia, coronary

artery abnormalities, or sepsis. Three cases of apparently

idiopathic myocardial infarction were identified and are

described in detail.

Conclusions Myocardial necrosis is relatively common in

infants who die and undergo autopsy, and is most com-

monly associated with congenital heart disease and peri-

natal asphyxia. Myocardial infarction can occur in infancy

in the absence of any apparent underlying cause: the eti-

ology of these cases is unclear.

Keywords Idiopathic myocardial infarction � Infant �Heart diseases � Myocardial necrosis

Introduction

Myocardial necrosis describes the damage and resulting

death of cardiac myocytes due to an external stimulus, and

when this external stimulus is a hypoxic insult, the

resulting myocyte destruction is referred to as myocardial

infarction. It is well recognized that myocardial necrosis

and infarction can occur in the neonatal period and infancy,

and has several associations including congenital heart

disease [1], congenital or acquired coronary artery abnor-

malities [2–4], perinatal asphyxia [5, 6], myocarditis [7, 8],

and tumors [2]. In some rare cases no underlying cause is

identified [9–13].

While the potential for myocardial necrosis in infants is

accepted, and such associations described, studies of fre-

quency have been contradictory, with incidence ranging

from no necrosis in unselected autopsy cases [14], to 29 %

of autopsy cases in neonatal intensive care populations

[15]. Given the relatively limited data available regarding

the true frequency of myocardial necrosis by cause in

infancy, the aim of this study is to investigate a large

number of infant autopsy cases from a specialist pediatric

pathology center, in order to identify those with myocardial

necrosis, and to describe in detail cases of apparently idi-

opathic myocardial infarction.

Method

Great Ormond Street Hospital, London, is a tertiary referral

center for pediatric investigation, including autopsies. An

A. R. Bamber (&) � J. Pryce � M. Ashworth � N. J. Sebire

Department of Histopathology, Camelia Botnar Laboratories,

Great Ormond Street Hospital for Children NHS Trust, Great

Ormond Street, London WC1N 3JH, UK

e-mail: A.bamber@ucl.ac.uk

A. Cook

Cardiac Unit, UCL Institute of Cardiovascular Sciences,

London, UK

123

Forensic Sci Med Pathol

DOI 10.1007/s12024-013-9472-0

autopsy database containing detailed non-identifiable data

from every autopsy performed at the center between Jan-

uary 1996 and December 2010 was searched to identify all

cases in which myocardial necrosis or infarction was

documented in the autopsy report. Necrosis was catego-

rized according to extent, anatomical location, type, and

other histological associations, such as inflammation, cal-

cification, or fibrosis. Descriptive statistics regarding the

findings in relation to clinical history, the underlying

diagnosis/cause of death, and any associated disease were

calculated, and cases of apparently idiopathic myocardial

infarction were described in detail. Ethical approval was

granted by the London (Bloomsbury) National Research

Ethics Service Committee (formerly Great Ormond Street

and Institute of Child Health Research Ethics Committee).

Results

A total of 1,637 infant autopsies were identified, of which

187 (11.4 %) showed histological evidence of myocardial

necrosis. Approximately one-third (54/187, 28.9 %) of

these deaths occurred during the first week of life, and two-

thirds (124/187, 66.3 %) within the first 90 days (Fig. 1).

Gestational age at birth was known in 136/187 cases and,

of these, 40.4 % were gestations below 37 weeks (55/136).

Histological inflammation was identified in 12.8 % of

cases (24/187), with nine of these having other features

sufficient for a primary diagnosis of myocarditis. Calcifi-

cation was recorded in 18.7 % of cases (35/187), and

fibrosis or granulation tissue in 16.0 % (30/187). The

degree of necrosis present was classified as being focal in

85/187 cases (45.5 %), severe/extensive/diffuse in 52/187

(27.8 %), and was not categorized in 50/187 (26.7 %).

In over half of cases (95/187, 50.8 %) the necrosis was

localized to the subendocardial region, papillary muscles,

trabeculae, or a combination of these. A localization to a

particular region of the heart was noted in 79 cases, of

which 40 (50.6 %) involved only the left ventricle or

interventricular septum, 12 (15.2 %) involved only the

right ventricle, and 27 (34.2 %) showed global ventricular

involvement. Descriptive terms for the type of necrosis

included ‘‘vacuolar’’ in 27 (14.4 %), ‘‘hypereosinophilic’’

in 32 (17.1 %), ‘‘contraction band associated’’ in 10

(5.3 %), ‘‘hemorrhagic’’ or ‘‘coagulative’’ in 32 (17.1 %),

‘‘ischemic’’ or similar in 59 (31.6 %), and as ‘‘necrosis,’’

‘‘infarction,’’ or similar in 70 (37.4 %).

The underlying likely cause for the necrosis has been clas-

sified based on the clinical history and autopsy findings, and

presented with details of the degree of necrosis present (Fig. 2).

Congenital and acquired structural heart disease and perinatal

asphyxia predominate, being associated with 56.1 % (105/187)

and 20.3 % (38/187) respectively. Focal necrosis tended to

predominate in cases of perinatal asphyxia, sepsis, lung dis-

ease, cardiomyopathy, tumor, coagulopathy, and left ventric-

ular aneurism, whereas diffuse necrosis was generally more

common in cases of coronary artery anomalies, intensive

care death, metabolic disease, myocarditis, idiopathic

necrosis, mechanical asphyxia, and death during surgery. In

the most common underlying cause category (congenital and

acquired structural heart disease), the proportion of necrosis

defined as diffuse or focal was almost equal in those cases

where it was given (51.7 % focal vs. 48.3 % diffuse).

The distribution of associations in those infants with a

recorded gestational age at birth of less than 37 weeks was

broadly similar to the study group as a whole. The pro-

portion of cases attributable to hyaline membrane disease

and perinatal asphyxia is similar in both groups (28.3 vs.

Fig. 1 Cumulative frequency

by age at death of 187 infants

with myocardial necrosis, from

a total population of 1,637

infant autopsies

Forensic Sci Med Pathol

123

27.3 %). However sepsis was more common in the pre-

mature group, accounting for 18.1 % of premature cases as

opposed to 11.2 % of cases in the total population.

Congenital heart disease and acquired structural

abnormalities

Congenital heart disease and acquired structural abnor-

malities (dilatation or hypertrophy of any chamber in the

absence of specific cardiomyopathy) was the commonest

etiological group, being associated with 56.1 % (105/187)

of the total cases of myocardial necrosis. 56.2 % (59/105)

of these involved surgical repair, although death could only

be attributed directly to surgery in one case, in which there

was sudden and dramatic intraoperative cardiorespiratory

collapse. The forms of congenital heart disease, according

to European Association for Cardio-thoracic Surgery/

Society of Thoracic Surgeons version of the International

Pediatric and Congenital Cardiac Code Diagnosis Shortlist

2012 [16] are shown in Table 1. All cases of isolated PDA,

PFO, ASD, or VSD, or combinations of only these

abnormalities, had other underlying associations which

could account for the presence of necrosis. Structural heart

disease involved multiple, severe, or complex abnormali-

ties in 50 % of cases (63/105).

Coronary artery abnormalities

Abnormalities of coronary arteries were present in 21 cases

(11.2 %), 81.0 % of them (17/21) being associated with

another form of congenital heart disease. Of the four

remaining cases, one was associated with sepsis and two

with myocarditis. Only one case had myocardial necrosis in

the presence of an isolated abnormality of left coronary

artery anatomy. This was a 113 day old infant who had

suffered intermittent episodes of breathlessness since birth

who had an episode of tachypnea, sudden collapse, and

cardiac arrest. At autopsy, the left coronary artery was

found to exit the aorta in an abnormal fashion, but no

luminal obstruction was seen; microscopic examination of

the heart showed necrosis with neutrophil infiltration.

Myocarditis

Myocarditis was a feature of nine cases, five of which were

extensive, diffuse, and/or severe (Fig. 3).

Genetic syndromes

Sixteen infants had a confirmed diagnosis of a genetic

syndrome (8.6 %); DiGeorge syndrome and Down syn-

drome predominate (11/16), and in all but one the cause of

the necrosis was congenital heart disease, the other being

an infant with Down syndrome who was born prematurely

and died of sepsis.

Tumors

Three cases were associated with the presence of a tumor;

two chest wall tumors with direct cardiac infiltration, and

0

10

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40

50

60

70

80

90

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Association

Not Stated

Diffuse Necrosis

Focal Necrosis

Degree of Necrosis

Fig. 2 Underlying association of myocardial necrosis, and degree of

necrosis present, in 187 infants with histologically-proven myocardial

necrosis from a total autopsy population of 1,637. *Congenital or

acquired structural heart disease. **Includes deaths following

prolonged intensive care, multiple organ failure and prolonged

resuscitation. ***Non-ARDS lung disease including pulmonary

hemorrhage/infarction/persistent pulmonary hypertension of the new-

born/hypoplasia. CA coronary artery, DAD diffuse alveolar damage,

ARDS acute respiratory distress syndrome, HMD hyaline membrane

disease

Forensic Sci Med Pathol

123

one with sepsis-like collapse associated with a renal tumor,

with no direct heart involvement. There were no cases of

an intrinsic heart tumor associated with necrosis.

Idiopathic myocardial infarction (cases with no specific

underlying cause)

There were three cases in which death was attributed to

myocardial infarction in the absence of any anatomical

abnormality of the heart or coronary arteries, or other

significant systemic pathology (Fig. 3):

Idiopathic case 1

An 80 day old male infant, born at term following a normal

pregnancy (birthweight 3,200 g), was well until the week

before death when his parents noted moaning, pallor, and

sweating. He worsened, suffering mild fever and episodes of

pallor. He was admitted to hospital where he was tachycar-

dic, with oxygen saturations of 80 % on 15 l of oxygen and a

capillary refill time of 3–4 s. Echocardiography showed a

hypokinetic enlarged heart. He suffered a cardiac arrest and

died. Autopsy demonstrated a normally formed infant. The

heart was enlarged (52.4 g vs. expected weight 23.0 g [17])

and globular, with a dilated left ventricle and macroscopic

myocardial congestion. There was no structural congenital

heart disease. Histological examination demonstrated cir-

cumferential subendocardial necrosis affecting the left

ventricular wall and papillary muscles. The areas of necrosis

showed brightly eosinophilic change with loss of nuclear

detail suggesting an age of at least 24 h. There was sparing of

the immediate subendocardial myocardium, and the myo-

cardium outwith the subendocardial zone was not affected.

The right ventricle and coronary arteries were normal and

there was no evidence of cardiomyopathy or vasculitis.

Examination of other major organs and all other post-

mortem investigations were unremarkable.

Idiopathic case 2

A 31 day old female infant, born at term following a normal

pregnancy and uncomplicated delivery, suffered a sudden

drop in oxygen saturation at 10 min of age. Echocardiogra-

phy showed poor left ventricular function with extensive left

ventricular thrombus. She was transferred to an intensive

care unit, but developed multiple organ dysfunction and

died. Autopsy, limited to examination of the heart and lungs,

demonstrated a normally formed infant. The heart was

enlarged (43.3 g vs. expected 20.0 g [17]) with a mottled left

ventricle suggestive of widespread infarction in the territory

of the left superior interventricular artery, and subendocar-

dial dystrophic calcification of the interventricular septum.

The inferior left ventricle and right ventricle appeared nor-

mal. There was no structural congenital heart disease. His-

tological examination showed an abrupt transition from

normal to necrotic and infarcted left ventricle and interven-

tricular septum, associated with granulation tissue and dys-

trophic calcification, as well as organizing laminated

thrombus. The coronary arteries were normal, and there was

no evidence of cardiomyopathy or vasculitis.

Idiopathic case 3

A 13-day old female infant, born at term following a

normal pregnancy and uncomplicated delivery, became

tachypneic at 12 h of age, dramatically deteriorated, and

was referred for extra-corporeal membrane oxygenation

(ECMO). Electrocardiography showed ST-segment chan-

ges, with a raised creatine kinase level. She developed

progressive multiple organ dysfunction and died. Autopsy,

limited to examination of the heart and lungs, demonstrated

Table 1 Types of congenital and acquired structural heart disease by

EACTS-SCS diagnosis category [16] identified in 105 infants with

histologically-proven myocardial necrosis and structural cardiac

abnormalities

Diagnostic category Number

(%)

Septal defects—atrial septal defect 52 (49.5)

Thoracic arteries and veins—patent ductus arteriosus 33 (31.4)

Septal defects—ventricular septal defect 28 (26.7)

Thoracic arteries and veins—coronary artery anomalies 24 (22.9)

Left heart lesions—aortic valve disease 17 (16.2)

Right heart lesions—tricuspid valve disease and Ebsteins

anomaly

12 (11.4)

Right heart lesions—pulmonary atresia 12 (11.4)

Transposition of the great arteries—transposition of the

great arteries

11 (10.5)

Left heart lesions—hypoplastic left heart syndrome 10 (9.5)

Left heart lesions—mitral valve disease 10 (9.5)

Right heart lesions—pulmonary valve disease 9 (8.6)

Thoracic arteries and veins—coarctation of aorta and

aortic arch hypoplasia

8 (7.6)

Septal defects—atrio-ventricular canal 7 (6.7)

Miscellaneous—other—hypoplastic right ventricle 6 (5.7)

Septal defects—truncus arteriosus 5 (4.8)

Pulmonary venous anomalies—total anomalous

pulmonary venous connection

4 (3.8)

Right heart lesions—tetralogy of Fallot 4 (3.8)

Thoracic arteries and veins—interrupted arch 2 (1.9)

Pulmonary venous stenosis 2 (1.9)

Double outlet right ventricle 2 (1.9)

Single ventricle—double inlet left ventricle 2 (1.9)

Double outlet left ventricle 1 (1.0)

Miscellaneous other—dextrocardia 1 (1.0)

Cases may be represented in more than one group

Forensic Sci Med Pathol

123

a normally formed infant. The heart was enlarged (26.0 g

vs. expected 19.0 g) [17]. There was no structural con-

genital heart disease. The myocardium appeared mottled,

particularly the left ventricle and interventricular septum,

with subendocardial pallor and dark red lesions within

myocardium. Histological examination demonstrated

extensive myocardial infarction with dystrophic calcifica-

tion. The coronary arteries were normal, and there was no

evidence of cardiomyopathy or vasculitis.

Discussion

The findings of this study have demonstrated that, first,

myocardial necrosis is a relatively common finding at

autopsy in infants, being most common in deaths occurring

in the first 90 days of life. Secondly, while the type and

extent of necrosis varies, it is most common in the sub-

endocardial region and papillary muscles. Thirdly, while

there are numerous associations with myocardial necrosis,

the majority of cases are related to structural heart disease

and perinatal asphyxia. Finally, although rare (0.18 % of

infant autopsies over 15 years), apparently isolated idio-

pathic myocardial infarction in the presence of normal

cardiac and coronary artery anatomy may occur and be

responsible for death.

These data demonstrate that myocardial necrosis is

present to some degree in around 10 % of infant autopsies,

and is much more common in deaths occurring at an early

age than those occurring later. Previous studies have

Fig. 3 Macroscopic photographs and photomicrographs showing

examples of typical features in infants dying with idiopathic

myocardial necrosis, and infants dying of myocarditis. a Opened left

ventricle showing myocardial discoloration and softening (Idiopathic

case 2, macroscopic photograph). b Papillary muscle showing areas of

hypereosinophilia and darkening due to necrosis (idiopathic case 3,

light micrograph 940). c Left ventricular myocardium showing

evidence of fibrosis, granulation tissue and hemorrhage in a case of

idiopathic myocardial infarction. The degree of inflammation is out of

keeping with the degree of necrosis (Idiopathic case 2, light

micrograph 9100). d Left ventricular myocardium showing myocyte

loss and prominent inflammation in a case of myocarditis. The

presence of marked inflammation with only minimal evidence of

necrosis is more typical of myocarditis with associated necrosis than

the inflammation associated with a primary infarct (myocarditis case

3, light micrograph 9200)

Forensic Sci Med Pathol

123

investigated the incidence of myocardial necrosis in

autopsy populations. A study of 135 consecutive autopsies

of infants and children found that none showed ‘‘conven-

tional’’ evidence of necrosis, although 96 of the cases were

hypothesized to show evidence of myocardial injury fol-

lowing staining with acid fuchsin [14]. A review of 84

patients dying on a neonatal intensive care unit below the

age of 1 month with no intrinsic congenital heart disease

found papillary muscle necrosis in 29 % of cases [15]. The

difference in frequency noted between these two studies

and our own is likely to be a result of differences in the age

ranges of the populations examined. The present series is

the first to examine a large number of unselected infant

cases.

The distribution of necrosis varied, but was most com-

mon in areas of the heart sensitive to ischemia; namely the

papillary muscles, trabeculae, and subendocardial region;

these regions together accounting for over half of cases.

This is unsurprising considering the high number of cases

which were associated with pathologies which might lead

to a state of relative hypoxia, or an increased oxygen

demand. The most common underlying associations iden-

tified in the present study were structural heart disease and

perinatal asphyxia, accounting for 56 and 20 % of cases

respectively. Previous studies have highlighted the impor-

tance of these associations [1, 5, 6] and this may partially

explain the young age at which the majority of deaths

involving necrosis occur, and the common distribution in

areas sensitive to hypoxia, as discussed above.

The most common association with necrosis was struc-

tural heart disease, accounting for almost half of the cases.

The mechanism by which myocardial necrosis occurs in

this setting is not always clear, but includes; necrosis

associated with foreign bodies introduced during medical

therapy, necrosis occurring in the context of multi-organ

dysfunction arising as a direct result of the cardiac abnor-

mality or as an incidental event, necrosis occurring in the

presence of multiple complex cardiac abnormalities, due to

a combination of circulatory failure and hypoxia, and

necrosis occurring in the presence of minor or uncompli-

cated abnormalities, such as an isolated patent foramen

ovale. In this latter group there were additional underlying

associations which might account for the presence of

necrosis.

As previously reported, abnormalities of the coronary

arteries were common, however most were associated with

other underlying cardiac abnormalities, or systemic

pathology such as sepsis; none of the cases in the present

series involved an isolated coronary artery thromboembo-

lus. In one case, necrosis occurred in the presence of an

isolated abnormality of coronary artery, presumably due to

a transient period of hypoxia, either through compression

of the vessel or by transient arrhythmia. This case

highlights the importance of careful examination of the

coronary artery anatomy at autopsy, even in the absence of

an apparent ‘‘cardiac history.’’

Myocarditis was the apparent underlying cause in a

number of cases but, as previous authors have noted, great

care must be taken in the interpretation of inflammation in

the heart in the presence of necrosis [8]. The distinction

between established myocardial infarction with inflamma-

tory response and true myocarditis with an associated area

of ischemia can be difficult, and the fact that the patient is

an infant should not result in an automatic diagnosis of

myocarditis. In particularly difficult cases the slides should

be referred to an appropriately experienced cardiac

pathologist for expert opinion. In true myocarditis, the

inflammatory response may be more generalized, and tends

to be out of proportion to the degree of necrosis present.

There were three cases with apparently isolated myo-

cardial necrosis/infarction, which could not be attributed to

prolonged intensive care or other underlying cause, in

normally formed infants with no cardiac anatomical

abnormalities. Similar individual cases have been previ-

ously reported [9–13]. It is possible that, despite careful

examination of the heart by specialist pathologists, such

cases are the result of a subtle abnormality of the cardiac or

coronary anatomy that was overlooked. Alternatively, and

more likely, such cases represent the result of transient

episodes of localized cardiac ischemia, possibly related to

arrhythmia or hypotension, with normal vascular anatomy.

These data suggest that such idiopathic necrosis is very

rare. In 2011 there were 3,154 infant deaths in the UK and

723,913 live births giving an infant mortality rate of 4.4/

1,000 live births [18]. Since these cases represent 0.18 %

of our study population, if we assume that this rate is

similar throughout the UK, then idiopathic myocardial

infarction would represent around five deaths per year in

the UK, equivalent to a rate of 7.8 9 10-6/1,000 live

births. It is noted that, while the clinical history and his-

tological findings are not characteristic, in light of the

markedly raised heart weights, particularly in cases one and

two, a diagnosis of idiopathic dilated cardiomyopathy

cannot be completely excluded in these cases. Families of

infants dying in such circumstances should therefore be

referred for genetic and/or cardiological opinion.

In summary, myocardial necrosis is a relatively common

finding at autopsy in the newborn and infant age group,

most commonly associated with structural cardiac abnor-

mality and perinatal asphyxia. Potential diagnostic pitfalls

include failure to identify small abnormalities of the car-

diac or coronary anatomy, and the distinction between

myocarditis and inflamed areas of necrosis, which can be

avoided by careful macroscopic and microscopic exami-

nation of the heart and coronary arteries, and referral for

specialist opinion where appropriate. Myocardial infarction

Forensic Sci Med Pathol

123

in infancy can occur as an isolated finding with no apparent

underlying cause; the etiology of these cases is currently

unclear.

Key Points

1. Myocardial necrosis is a relatively common finding in

infants at autopsy.

2. Myocardial necrosis in infants has a number of

common underlying associations include congenital

heart disease, coronary artery abnormalities, and

perinatal asphyxia.

3. Myocardial necrosis in infants is most common in

areas of the heart that are most sensitive to hypoxia.

4. Myocardial infarction can rarely occur in infants in the

absence of an identifiable underlying cause.

Acknowledgments ARB is supported by a grant from the Lullaby

Trust. NJS is part supported by GOSHCC and the NIHR GOSH BRC.

This article presents independent research funded by the National

Institute for Health Research (NIHR). The views expressed are those

of the author(s) and not necessarily those of the NHS, the NIHR or the

Department of Health.

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