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A 38 year old man was admitted for medicolegal necropsy because of sudden death following transitory chest pain. He had been a heavy smoker and suffered from chronic bronchial asthma. The asthma was adequately treated by inhalation of bronchodilators and he did not receive any other kind of medical treatment. He had never experienced cardiovascular symptoms and there was no history of rheumatic disease. While sitting as a passenger in a car, he suddenly complained of severe chest pain. A moment later he lost consciousness. He was immediately taken to a doctor, who declared him dead. Necropsy revealed cardiac hypertrophy. Body weight was 58 kg and heart weight 394 g. The left ventricle measured 15 mm and the right ventricle 5 mm. Posteroseptally in the left
ventricle there were several areas of subendocardial fibrosis. On the left aortic valve, a friable stalky excrescence (18 mm × 3 mm) was located (below left). There were no valve deformities. Microscopically the excrescense consisted mainly of fibrin and erythrocytes on top of a fibrous/myxomatous string (below right). There were no microorganisms. Death was caused by the mobile non-bacterial thrombotic excrescense, which had occluded the left main coronary artery. The stalk of the excrescense may be a congenital string. The old infarcted areas may represent embolic phenomena from the friable excrescense.
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