External cardioversion-related cardiac damage

Significant iatrogenic injury of the heart is an uncommon occurrence. Described is a unique case of electrical cardioversion injury of the heart. A 58-year-old man underwent orthotopic cardiac transplant for end-stage ischemic heart disease. Five months posttransplantation, he experienced severe acute rejection and developed progressive heart failure and atrial flutter, which were not responsive to medical treatment. The patient required external electrocardioversions, which were unsuccessful despite progressively increased voltage. He died of heart failure approximately two weeks after admission. Postmortem examination revealed the sequelae of acute and chronic heart failure, patchy myocardial fibrosis (healing rejection), ongoing mild to moderate acute rejection, and marked subepicardial wedge-shaped necrosis in the left ventricular free wall. The microscopic age of these areas was consistent with their occurrence at the time of attempted cardioversions, approximately seven days before death. Pathologists should be aware of this iatrogenic injury (and its morphologic pattern), so that it is not confused with ischemic or other forms of myocardial damage.