J Indian Acad Forensic Med. July-September 2013, Vol. 35, No. 3
ISSN 0971-0973
Case Report Sudden Death due to Ventricular Free Wall Rupture Following Acute Myocardial Infarction: A Rare One *Abhishek Das, **Sujash Biswas, **Chandan Bandyopadhyay, ***Chittaranjan Bhattacharya, ***Deepsekhar Dalal
Abstract Hemo-pericardium due to ventricular free wall rupture (FWR) as an immediate complication (within 1 to 14 days) of acute myocardial infarction is a rare cause of sudden death. It is infrequent occurring in 2–6% of all infarctions, but having high mortality (20–30%). The patho-physiological process of FWR involves thinning of myocardial wall with the intensity of necrosis occurring at distal end of the vessel where there is often poor collateral flow. The shearing effect of myocardial contraction against a stiffened necrotic area causes rupture. Most common rupture location is on the anterior or lateral wall of left ventricle. A mid-ventricular position along apex-base axis is most common. Such a case was declared brought dead in emergency of NRS Medical College and Hospital and post-mortem examination was done which revealed ventricular free wall rupture adjacent to left anterior descending artery occlusion leading to Hemo-pericardium as cause of death. About 450 gm clotted blood was present surrounding the heart. It has been attempted in this presentation to put forward findings of such a rare case and relevant discussions.
Key Words: Haemo-pericardium, Ventricular free wall rupture, Death, Left anterior descending artery Introduction:
Case History:
Death is said to be sudden or unexpected when a person not known to have been suffering from any dangerous disease, injury or poisoning is found dead or dies within 24hours after the onset of terminal illness. Natural death means that the death was caused entirely by the disease, and the trauma or poison did not play any part. [6] Cardiovascular causes are most commonly responsible for this in about 45-50% cases and Acute Myocardial Infarction (AMI) is leading entity. [5] A hemopericardium due to left ventricular free wall rupture (LVFWR) is a complication of acute myocardial infarction (AMI) and is rare cause of sudden death. A careful dissection and observation during autopsy can detect such an unusual finding as the cause of death.
The subject was a 60 years male patient who suddenly fell down from the staircase after having a sudden syncopal attack and was unresponsive since then. He was brought to the Emergency Department of NRS Medical College and Hospital where he was declared brought dead. Police made an inquest as it was a case of sudden death and referred for medico-legal autopsy to the mortuary wing of Department of Forensic and State Medicine, N. R. S. Medical College, Kolkata, West Bengal.
Autopsy Findings: External Examination: The subject was moderately nourished and of medium complexion. On examination rigor mortis was present all over the body, pupils were bilaterally dilated and fixed, and cornea was hazy. Externally a bruise of dimension 1”x1” was found on the left malar prominence which was red in colour and showed the signs of vital reactions on examination. No other external injury was found even after careful examination with a hand lens. Internal Examination: Pericardial sac was full of clotted blood weighing 450grams. The layer of clot covered almost whole of the heart when pericardium was dissected out. On removal of the clot and separation of the pericardium a large sized heart
Corresponding Author: nd
* Post Graduate Trainee II Year, Department of Forensic and State Medicine, N. R. S. Medical College, Kolkata-700014, West Bengal E-mail:
[email protected] rd rd **3 year Post Graduate Trainee III Year nd *** Post Graduate Trainee II Year DOR: 16.5.13 DOA: 19.8.13
291
J Indian Acad Forensic Med. July-September 2013, Vol. 35, No. 3 was visible weighing 500 grams. Heart was dissected carefully and on dissection both the ventricles were found enlarged along with grade II and grade III atheroma at the root of the great vessels. An atheroma was found to occlude the anterior descending branch of left coronary artery. A region of erosion of left ventricular wall was found along with evidence of blood clots at places.
ISSN 0971-0973
References: 1. 2. 3. 4.
Discussion:
5.
Myocardial rupture is an early complication of AMI with bimodal peak of incidence (within 24 hours and 3-5 days), range being 1-14 days. It may present as ventricular free wall rupture, papillary muscle rupture or ventricular septal rupture. [1] Ruptured heart is the most common cause of hemo-pericardium and cardiac tamponade, the rupture always occurring through an infarct. [2] The overall rate of mortality due to ischemic heart disease is known to increase progressively with age. [3]First attack of AMI, h/o hypertension, no previous h/o angina pectoris and relatively large q wave infarct are associated with higher incidence of cardiac rupture. The traditional risk factors of LVFWR are older age, female sex, previous hypertension, and a first lateral or anterior-wall AMI. [4] Clinical presentation is sudden loss of consciousness, pulse and blood pressure. Myocardium continues to contract but forward flow is not maintained as blood escapes into pericardial cavity. Cardiac tamponade ensues and closed chest massage becomes ineffective.Though AMI is the commonest cause, sudden, but death due to LVFWR following AMI leading to hemopericardium is very rare. It is almost always fatal yet dramatic cases of pericardiocentesis followed by successful surgical repair have been reported.
6.
Antman EM et al. Myocardial infarction: Management in Braunwald’s Heart Disease, 9th Ed, RO Bonow et al. (eds.), Elsevier Saunders, 2012, 1146-1148 Knight B, Saukko P. The pathology of sudden death in Knight’s Forensic Pathology, 3rd Ed, P Saukko & B Knight (eds.), Arnold, 2004, 497-526 Maggioni AP et al. Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. N Engl J Med 1993; 329:1442-1448. Amir O et al. Left ventricular free wall rupture in acute myocardial infarction. Tex Heart Inst J. 2005; 32(3):424-426 Mukherjee JB. Injury and its Medico-legal aspects 2007, 3rd ed, Karmakar R.N., Academic publisher, p226-228. Reddy KSN. The Essentials of Forensic Medicine and Toxicology, 30th Edition. K.Saguna Devi, Hyderabad, 2010; p128-136.
Fig. 1: Cardiomegaly
Fig. 2: Blood Clot Covering the Heart after Removal of Pericardium
Fig. 3: Infarct Area of Heart Pointed with Scalpel
Conclusion: Medico-legal autopsy is done in cases of sudden, suspicious and unnatural deaths. Though AMI is the most common cause of sudden death, yet ventricular free wall rupture as a complication of AMI is furthermore rare cause. Detection of such rare finding may guide and help to take precautionary measures to save the life of individuals who have a history of AMI as these complications remain unnoticed and often ignored clinically. Therefore careful dissection and thorough examination during autopsy is the only key to success for finding the cause of death.
Fig. 4: Area of Ventricular Free Wall Rupture Pointed With Arrow
292
