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Case Summaries and Teaching Objectives
This case is good for an introduction to autopsies and basic anatomy. The audio is conversational which eases in students who are earlier in training and lightens the experience. A variety of autopsy tools are also on display.
1. Familiarize with basic internal anatomy of chest and abdomen.
2. Reflexively incorporate obesity into physical assessment and consider health risk factors related to obesity when caring for patients.
3. Develop an active strategy to accept and manage medical uncertainty (limited clinical information). Learn the value of formulating questions and strategies to fill in gaps even if answers aren’t available.
4. Identify and explain general stresses or risks related to any hospitalization or chronic illness (nutrition, deep venous thrombosis, nosocomial infections, medication alterations, etc.).
5. Write example discharge instructions for this case (pneumonia) and other basic medical admissions (myocardial infarction, diabetes, etc.). Discuss the importance of home-care planning after an admission.
This case shows aspiration. Gastric contents are identified in the airway (Part 2). There is also an anatomic abnormality of the airway (fixed narrowing, Part 3) that made intubation difficult.
1. Identify and explain common physical exam and special care needs in immobile and nonverbal patients (nutrition, tube feeds, decubitus prevention, chronic disease management, routine testing, etc.).
2. View an example of documented aspiration (stomach contents in airway).
3. Review aspiration precautions and positional risks (elevated head of bed vs. Trendelenburg, etc.)
4. Discuss the importance of family caregivers, partnership with the provider for care, and how to talk to caregivers ethically when their loved one becomes ill under their care.
5. Review and view intubation/airway anatomy.
6. Discuss possible reasons for “difficult intubations,” and view an example (rigid, narrow airway).
7. Discuss “competence” and when to ask for help as a provider
The patient died after having rib pain he thought was musculoskeletal. The autopsy showed serious blockages in the coronary arteries. The presence of pulmonary congestion correlated with heart failure and supported a cardiac cause of death. The patient’s risk for coronary artery disease was most likely his smoking (by history) and also evidenced by emphysema (pulmonary apical blebs).
1. Describe key history-taking and physical examination skills to distinguish between life-threatening and non-life-threating chest pain.
2. Review risk factors and physical findings correlating with cardiovascular risk (smoking, obesity, emphysema, etc.).
3. Review mechanism and pathophysiology of heart attack.
4. Understand coronary artery dominance (the patient is left-dominant).
This case is a good illustration of advanced cancer (mesothelioma).
1. Understand mesothelioma (causes, common locations and presentations, etc.). This patient’s tumor originated in the abdomen.
2. Explain the difference between local tumor spread and metastases.
3. Discuss the factors that go into late diagnosis of cancer (anatomic, social-emotional, health care access, screening, educational).
4. Review limitations of radiography in anatomic definition. (The patient’s tumor was thought to be attached to the heart, but was attached to the pericardium.)
5. Review types and causes of pleural effusions (serous, malignant, parapneumonic, etc.) and view an example in this patient.
This case primarily illustrates brain and cranial anatomy. The case is not embalmed. For contrast, view Case 19, which is embalmed. Make use of the extensive Anatomy Pins in each case. Remember, the list of anatomy terms can be scrolled up and out of the way to allow “self-check.” And be sure to use the “short rewind” option for 3-d perspective. (Find instructions above any Anatomy video option.)
1. Review base of skull anatomy. (There are detailed Anatomy Pins.)
2. Review brain anatomy in a non-embalmed case. (These are older videos. Please also view Case 19 for a more recent case and more Anatomy Pins.)
This case is of a spinal fusion surgery followed by numerous complications: mental status changes (first considered related to medications, then considered possibly related to central nervous system infection — although this could not be proved); and back abscess requiring multiple surgeries.
1. Review body “symmetry” as diagnostic tool in physical examination technique (comparing side of the body to highlight differences and help diagnose disease).
2. Review basic spinal anatomy; view spinal cord, cauda equina and spinal canal. (Anatomy is very basic in this video.)
3. Review degenerative disc disease and surgical treatments. (View an example of a spinal cage.)
4. Review complications of spinal surgery.
The family requested the autopsy because they were concerned the inferior vena cava filter had migrated and caused problems for the patient. (Is this a realistic or possible complication of inferior vena cava filters?) They requested that the inferior vena cava be retrieved during the autopsy. They also wanted to know information about the cause of death. The patient had been seen recently for shortness of breath, but the cardiac work-up was negative. They also requested a brain evaluation because the patient had had a head injury from a fall (remote) requiring craniotomy.
1. Review inferior vena cava filters, reasons for placement and complications. (View scarring of the filter onto the inferior vena cava wall.)
2. Review head trauma, surgical treatment for intracranial hemorrhage, and long term outcomes. (The patient had a remote head injury, craniotomy with burr hole, and a resolved/resorbed bleed.)
3. Review sudden death from cardiac disease (coronary atherosclerosis and myocardial infarction vs. hypertension and arrhythmia).
The patient had kidney failure (requiring peritoneal dialysis) and cirrhosis (from prior alcohol use disorder). Because of portal hypertension, he underwent a TIPS procedure to help him get ready for a kidney-liver transplant. The TIPS procedure was complicated by hypotension. There was no documentation in the medical record that the post-operative care team knew about intraoperative hypotension. The patient went into liver failure and then multiorgan failure in the immediate post-operative period. And then died.
1. Review kidney failure and treatment modalities. (The patient received intraperitoneal dialysis.)
2. Review alcohol use disorder, cirrhosis and portal hypertension. (The patient had cirrhosis and received a TIPS procedure in preparation for transplant.)
3. Review shock (septic, cardiogenic, hypovolemic). (The patient was hypotensive during the TIPS procedure, then developed organ failure. View a bowel infarct, hepatic infarct and related laboratory data.)
4. Discuss ethics of team communication; and the importance of reporting intraoperative or other adverse events to the patient and team. (The post-operative team was not aware of the intraoperative hypotension and did not know to take steps to increase postoperative monitoring.)
The purpose of the case is to review a spleen dissection. Review spleen anatomy, physiology and pathology. In the autopsy, the spleen is often helpful to assess for portal hypertension and/or right heart failure. The tell-tale finding is an enlarged, congested spleen (congestive splenomegaly). The video also shows a common anatomic variation (accessory spleen/spleniculus).
1. View spleen anatomy with accessory spleen (spleniculus).
The patient had a polypectomy complicated by bowel perforation. The polyp was quite large and sessile (wide) as can be seen (Part 7) by the large surgical removal area (there is a defined gap in the mucosa). The polyp removal was likely complicated by bleeding (evidenced by the metal colonoscopy clips). This was likely not an easy procedure. The evidence also points to a perforation (free air, per radiography; and an inflammatory response by autopsy). Lastly, there is extensive hemorrhage in the large intestine (Part 6).
1. Review colon and small intestine anatomy.
2. Review colonoscopy procedure, indications for polypectomy, use of colonoscopy clips, complications.
3. Review pathophysiology of ascites. (The patient had ascites.)
4. Review peritonitis. (The patient had peritonitis.)
The case is of an elderly woman who died suddenly following activity (walking down stairs). She had recently been sick (gastrointestinal bleeding of undetermined etiology).
1. Review causes of upper vs. lower gastrointestinal bleeding. (The patient had mild upper gastrointestinal bleeding.)
2. Review etiologies of catastrophic vs. occult bleeding.
3. Review acute gastritis.
4. Review deep venous thrombosis and pulmonary embolism.
The case is of a middle-aged man with an unwitnessed arrest and a variety of risk factors.
1. Review deep venous thrombosis and pulmonary embolism.
2. Review cause of pulmonary edema (unilateral vs. bilateral).
3. Review dural anatomy.
This is a complex case of a patient with multiple medical problems. It’s good for practicing a systematic approach to analyzing the history and physical findings. Anatomy pins videos are available for multiple parts (Parts 3, 5, 8, 9, 10, 11). Have students make use of these to assist with the process.
1. Practice assigning clinical importance to varied historical information.
2. Review sudden cardiac death (hypertensive – catastrophic aortic rupture; hypertensive – arrhythmia; ischemic; etc.).
The case is good for considering the differential diagnosis and work-up of “chest tightness.” “Chest tightness or discomfort” was the patient’s symptom, but his recent (unspecified) cardiac work-up was negative and, at autopsy, his coronaries were generally “clean.” He did not have a heart attack. The lesson for clinicians is to consider the importance of alternatives to coronary artery disease in this situation. The heart was very enlarged (Part 9) and weighed 540 grams (normal 400-450 grams). The left ventricle was hypertrophied (Part 9). These findings fit for hypertensive heart disease. The patient likely went into an abnormal rhythm due to his hypertensive heart disease. The edema and congestion in the lungs (Part 7) fit for cardiac pump failure, and support the diagnosis. (Educator tip – information not provided in the videos: the left ventricular wall thickness was 1.6 cm (normal typically less than 1.2 cm).)
1. Distinguish between hypertensive cardiac disease and ischemic cardiac disease. Determine which clinical features overlap and which are unique/distinct.
The case illustrates narcotic overdose in the setting of chronic use for chonic pain. The postmortem toxicology test may be found in Part 3.
1. Review chronic pain and management options.
2. Review opioid-related treatment issues and testing.
3. Learn detailed distal forearm anatomy.
The case primarily illustrates a brain removal and cranial anatomy. The case is not embalmed. The audio is conversational because the case was livestreamed. Follow along for a general tour and description as the procedure unfolds. This case does not have anatomy pins. Learn the structures on a case that does have anatomy pins (for example, Case 5 Part 1 or Case 35 Part 2). Then, come back and try to identify the same structures here. Institutional groups can use the interactive video to identify and label structures.
1. Learn brain external anatomy and base of skull anatomy.
2. Review dementia diagnostic criteria and uncertainty.
This case is a basic “chest only” assessment for an unwitnessed cardiopulmonary arrest. The cause of death is likely acute myocardial infarction. There are petechiae visible around an old, healed myocardial infarction (posterolateral left ventricular scar, Part 4); and an occlusion identified in the proximal left anterior descending coronary artery (Part 5).
1. Learn external cardiac anatomy.
2. View example of severe coronary atherosclerosis. (Hear audio of “crunch” of a calcified coronary artery during dissection.)
3. Review sudden cardiac death.
This case illustrates decomposition and a brain removal. The patient had a history of a clipped cerebral aneurysm.
1. Review cerebral aneurysm, symptoms, and treatment. (The patient’s aneurysm was treated in the past, but aneurysm was in the differential diagnosis for the case.)
2. Review coronary artery disease.
The case is primarily a view of neuroanatomy. There is a meningioma. The family history suggests inherited cancer. Review symptoms of brain mass — in general and in this patient’s location (posterior cranial fossa). Could it explain the patient’s dizziness? Or was the tumor incidental at autopsy? The case was embalmed. Make use of the Anatomy Pin videos to review neuroanatomy.
1. Learn detailed external and internal brain anatomy.
2. Generate a differential diagnosis for acute and chronic dizziness.
3. Review meningioma.
4. Learn about familial/inherited cancers.
The case provides a good general anatomic inventory. It includes a fairly complete set of organs. There are Anatomy Pin videos for most of the case parts (Parts 2, 3, 4, 5, 7). There is also detailed neuroanatomy (Part 7). The cause of death is likely related to hypercholesterolemia and stroke (see below).
1. Review the management of stroke patients.
2. View a large recent ischemic stroke (within the past few months).
The case is in development. However, the cases is good for viewing a breast lumpectomy scar, the female internal organs, and a discussion of alcohol use disorder. The will be updated with additional parts and information.
1. View basic female internal anatomy.
(Case in development. Please stay tuned for updates.)
The case is good for a review of basic anatomy and toxicology.
1. Understand the concept of postmortem redistribution.
2. Understand toxicology reports, and specifically how to interpret results for psychoactive drugs with a low likelihood of overdose.
This case illustrates a Roux-en-Y procedure with post-operative complication of pulmonary embolism. There is also a released gastric band (Part 4). Have students learn how a Roux-en-Y rearranges anatomy and see if they can puzzle through the different segments and connections in the video.
1. Review risks and management modalities for obesity, including surgical options and their complications.
2. View a Roux-en-Y procedure
3. Review pulmonary embolism.
The purpose of the case is to show a coronary artery bypass graft surgery. The patient had a late complication (surgical ostium scarred closed — Part 3, 00:00 – 00:22). The case is embalmed.
1. Review complications of coronary artery bypass graft surgery. (This patient had scarring and closure of the surgical ostium.)
2. Determine which complications may be related to the procedure itself; to the patient’s post-operative care, self-care or disease severity; or to the body’s natural healing processes (clot formation, scarring).
The case illustrates a low-speed motor vehicle accident. The patient tore his aorta while driving (a medical problem from hypertension) and then crashed. Compare with Case 35 — a high speed motor vehicle accident with visible seat belt impression marks and a severed spine, aorta and inferior vena cava.
1. Review complications of hypertension.
2. Review treatment and compliance issues in hypertensive patients and formulate engagement strategies as a clinician. (This patient stopped taking hypertensive medications, switched to herbal remedies, and then died from a hypertensive aortic tear.)
The case illustrates severe bruising (face, conjunctiva, right shoulder, foot) from a nursing home fall. There is only one part to the case — an external exam. Addition information for educators (not present in the case videos): The patient did not die from her injuries but from a pulmonary embolism a couple weeks after the fall.
1. Review falls in the elderly.
2. Review how to distinguish between accident, abuse and neglect; and special concerns in the elderly (non-verbal states, pre-existing conditions that can confound assessment (easy bruising), family dynamics, etc.).
The case illustrates a young dialysis patient with chronic pulmonary embolism. There are clinical mysteries to the history as well as ethical issues in this case. The coumadin was discontinued two months prior to death and for unknown reasons (although it is possible this was in preparation for operative removal of her chronic pulmonary embolism). In addition, the patient had an event at dialysis on the day of death. She became hypotensive and symptomatic and died after the paramedics were contacted (see below).
1. Review causes of kidney failure in a young patient.
2. Review different types of dialysis grafts and their complications.
3. Review chronic pulmonary embolism.
4. Review importance of blood pressure management — in general and in dialysis.
5. Discuss the ethics of patient communication and decision-making. (Can a clinically unstable patient refuse care?)
The case illustrates a variety of medical and diagnostic errors in a patient with peripheral vascular disease. The patient presented with leg pain and underwent vascular surgery of the lower leg to clear arterial blockages. The surgery was complicated by reperfusion syndrome post-operatively. The patient was sent home and her pain got worse. Yet, when she came back to the hospital, her angiographic studies were unchanged. The clinical team noticed they were unchanged, but because her pain had worsened presumed there was some re-occlusion. (See the section in the History titled “Emergency room physician note.”) A second surgery was performed during which the patient was tachycardic. She was also tachycardic in the post-operative period. The patient coded and died.
1. Review distal leg anatomy.
2. Review peripheral vascular disease, symptoms, presentation, treatment, and follow-up.
3. Learn about reperfusion syndrome.
4. Learn about compartment syndrome.
5. Review how to mitigate risk of cardiac ischemia in a patient with coronary artery disease. (This patient with severe peripheral vascular disease had severe ongoing leg pain leading to tachycardia leading to ischemia, myocardial infarction and death.)
6. Review the importance of evidence-based decision-making. (The patient underwent a second vascular procedure without diagnostic, evidence-based support and with a missed diagnosis of compartment syndrome.)
7. Discuss the importance of listening to the patient.
This case illustrates a classic scenario for pulmonary embolism: illness (accompanied by resting), followed by unilateral leg swelling (deep venous thrombosis), followed by sudden death. The autopsy identified the pulmonary embolism (Part 4).
1. View a classic example deep venous thrombosis and pulmonary embolism (history of rest due to illness, leg swelling, clot in popliteal vein, clot in pulmonary artery).
This illustrates sudden death in a patient with a coronary artery bypass surgery and alcohol use disorder.
1. Review sequelae of alcohol use disorder. (In this case, there was trauma. The patient fell and re-injured/tore a prior patellar tendon surgical repair.)
2. Review coronary artery bypass graft procedure.
The case shows a homicide from blunt force trauma. There are defensive injuries on the arms and legs and contusions of the scalp with an implied skull fracture (supported by the presence of intraosseous blood inside the petrous bone).
1. View an example of a homicide.
2. Learn about defensive injuries. ( View on the arms and legs.)
3. Learn about blunt force trauma of head. (The patient has scalp contusions and an implied skull fracture (intraosseous bleeding).)
This is a limited portion of an autopsy with toxicology testing. The case highlights neck anatomy (Part 3). Have students analyze the toxicology. The toxicology is non-contributory, and the alcohol is likely from postmortem bacterial production.
1. Consider causes of mental status change in the elderly.
2. Understand toxicology reports, and, specifically, interpreting results of psychoactive drugs with low likelihood of overdose.
This case illustrates hemorrhagic cardiac tamponade (Part 2) and an aortic tear (Part 3) in a patient with a history of hypertension.
1. Distinguishing hypertensive symptoms related to the heart vs. ischemic symptoms.
The patient a had a stent placed after presenting with an acute myocardial infarction. The stent was inserted through her right groin. After the procedure, she lost her pulse in the right foot and was tachypnea. The tachypnea was attributed to anxiety and the patient was prescribed Ativan. However, she was having massive internal bleeding from her groin site and was hypotensive the next day. The bleed was identified, and an arterial patch was placed, but the patient died.
1. Review cardiac catheterization and its complications (both in the heart and also at the catheter insertion site in the groin).
2. Review clinical assessment of lower extremity circulation. (Which signs and symptoms indicate arterial issues? And which indicate venous issues? This patient lost her pulse in the foot after catheterization in the groin.)
3. Review abdominal wall anatomy.
4. Discuss the ethics of team communication and listening to team members. (The nurse called the on-call doctor to report an absent foot pulse. He prescribed anxiolytics while she went into shock and bled to death.)
5. Review signs of shock (including mental status change). See also Case 44, where the patient had hypertension. Then his blood pressure normalized (but it was because he was bleeding to death internally and in shock).
This case illustrates a high-speed motor vehicle accident. The body is embalmed. You can see the seat belt impression marks and external contusions. The spine is split, as is the aorta and inferior vena cava.
1. View an example of a high-speed motor vehicle accident. (The patient has a severed vertebral column, aorta and inferior vena cava.)
2. Learn detailed base of skull anatomy.
This case illustrates internal bleeding from a fall. The case is also useful to correlate the external exam (Part 1) and the found position of the body (skin slip on the right arm). There is also subtle bruising at the right inferior costal margin. This correlates with the location of internal bleeding (right upper quadrant) and supports injury as a cause of death. Discuss the possible etiologies of right upper quadrant bleeding.
1. Understand causes, management and risks of syncope.
2. Understand falls. (The patient died from internal bleeding after a syncopal episode.)
This is an advanced case to consider. The autopsy showed bleeding vessels in the duodenum. Educator tip (histology information not available yet in the case): the patient had cirrhosis. The bleeding vessels were likely varices related to portal hypertension. Use the case history to consider a variety of causes of death.
1. Review early symptoms of renal failure. (This patient had a “metallic taste” that was misdiagnosed by the family first as a water-supply problem, and then as a “corroded” pacemaker. The clinician ended up removing the pacemaker, likely an unnecessary procedure).
2. Review cirrhosis and portal hypertension. (The patient died from bleed duodenal varices.)
3. Discuss the ethics of provider competence and how to manage internal and external pressures. (Discuss what knowledge, relationship and training skills would strengthen clinical judgment in a case like this where there was likely an “unnecessary procedure.”)
This patient with Crohn’s disease received an unnecessary procedure (lung resection) and then died from complications (bowel rupture with multiple cardiopulmonary issues). There were biopsies for a lung mass, none of which were conclusive. But an operation was performed for a presumptive diagnosis of cancer. The lung mass, on resection, was a fungal granuloma. Follow the “Discuss questions” in each part to expand the case concepts.
1. Learn about work-up, diagnosis and management of solitary pulmonary mass.
2. Discuss the importance of evidence-based decision-making. (The patient had a cancer surgery after a non-diagnostic biopsy. It was a fungal infection.)
3. View peritonitis with bowel rupture in a patient with Crohn’s disease.
4. Learn about the VATS procedure.
5. Review Crohn’s disease.
The patient had autopsy findings of cirrhosis, portal hypertension, and a splenic vein thrombosis. Massive splenic hilar hemorrhage caused the death. Sort through the history. Does it seem like the initial problem was traumatic, left upper quadrant bleeding? Or did the patient collapse for some other reason and then the bleed from CPR-related trauma? What’s the evidence, based on the history and autopsy findings. Tip: The history was from the family. Consider issues of reliability, but also consider it may be accurate. They report a “slow pulse” at home while the patient was collapsing. Would this fit with internal bleeding? How do you make sense of the case?
1. Understand the clinical implications of bradycardia vs. tachycardia.
2. Understand portal hypertension and its sequelae.
3. View an example of traumatic hemoperitoneum.
This case illustrates the consequence of smoking. The patient had multiple cancers, multiple cancer surgeries, and multiple surgical complication. She died during a biopsy of a new lung cancer. Make sure student know that patients with one lung cancer (even after treatment) are at increased for a second lung cancer (a completely new primary). Many physicians do not communicate this to their lung cancer patients. And, as a result, patient think the “surgeon didn’t get it all out” if they get a cancer later. The new cancer is typically not a metastasis or something the surgeon missed. It’s a completely new cancer.
1. Review smoking as a cause of multiple types of cancers. (The patient had two separate lung cancers and laryngeal cancer.)
2. Review the natural history of lung cancer. Review that patients with one lung cancer are at risk for a second, separate lung cancer.
3. Review the intestinal autotransplant procedure.
4. Review the lung biopsy procedure, risks and complications. (This patient died from massive hemorrhage into the airway There was a large artery near the site of tumor.)
The case illustrates uremic pericarditis. The history is from the family. What parts are reliable? Are there any tipoffs in the history that uremic pericarditis might have been the diagnosis? What about the weight gain? The case shows anasarca (extensive subcutaneous fluid – Part 2). Did the patient have undiagnosed renal failure?
1. Review complications of renal failure (uremic pericarditis, weight gain, anasarca).
2. Discuss the role of patient vs. provider in ensuring care. (The provider did not seem to provide discharge medications; but what was the family’s role, knowing they needed them?)
The case illustrates massive acute (Part 2) and subacute (Part 3) pulmonary embolism. There is no physical exam for this case.
1. Review acute and chronic pulmonary embolism.
This case illustrates traumatic subarachnoid and subdural hemorrhage. The case is designed to allow students to function like an independent medical examiner or pathologist. There are no discussion questions and no explanatory audio. This is deliberate. Students should go into this case as though they have only the history, their observations and their own skills to make sense of the case.
1. Review fall management in the elderly.
2. View a coup-contrecoup head injury, unilateral cerebral edema, and duret hemorrhages.
The case illustrates post-renal (obstructive) acute renal failure. The cause was a benign condition (benign prostatic hypertrophy). The onset of renal failure was accompanied by hypertension and syncope. The hypertension resolved after the patient was admitted (the patient became normotensive just before death). The patient’s shift from hypertension to normotension on admission was likely a sign of hypovolemic shock, not “clinical stability.”
The autopsy showed massive hemoperitoneum, aortic dissection, hydronephrosis, hydroureter, and a massive prostate with benign nodules obstructing the prostatic urethra.
1. Review the postrenal obstruction, its causes and consequences (in this case, benign prostatic hypertrophy).
2. Review the presentation of acute renal failure (in this case, hypertension).
3. Review hypertensive crisis presenting with arterial rupture.
4. Review the importance of incorporating historical data when interpreting single values. (In this case, the patient’s hypertensive crisis resolved, but it’s because he was going into shock from internal bleeding, not because he was stable and his hypertension had “gotten better”. Normal blood pressure values in this case reflected a worsening crisis, not improvement.
The case shows likely ischemic heart disease as the cause of death. There is severe blockage of the left mainstem coronary artery and severe pulmonary edema.
1. Review sleep apnea and its consequences.
2. Review cardiac sudden death.
The case illustrates rupture of pacemaker lead through the ventricular septum, through the pericardial sac and into the mediastinum where it abutted the back of the anterior rib cage. This set up a massive inflammatory process (pericarditis, pleuritis, empyema). The rupture likely occurred around a week prior and correlated with the patient’s sudden onset of “new” pain at that time. The time frame of a week also correlates with the amount of inflammation (massive) present in the body. The degree of inflammation could not possibly form in one day, for example. (In other words, the rupture did not occur during CPR.) A more remote rupture (say, months prior), would also be unlikely. This becase a more remote rupture would likely show some chronic changes (e.g., scarring). Chronic changes are less prominent in the case.
1. Review how to take a history to distinguish between life-threating cardiac-related symptoms and non-life-threating (e.g., esophageal, musculoskeletal) symptoms.
2. View an example of pacemaker lead rupture through the septum of the heart.