Blunt cardiac rupture is a characteristic of high death rates and rapid death process. But sometimes it is hard to find out the cause of cardiac rupture of traumatized patients, especially when it relates the relationship between injury and disease. In the 2 cases reported herein, both of the 2 patients had pre-existent cardiac pathological changes when suffered from traumatic injury. Our aim is to evaluate autopsy findings from a medicolegal point of view, and offer our proposals on how to deal with this sort of cases.
Blunt cardiac rupture (BCR), being a characteristic of high death rates and rapid death process, is found mostly in falling injury and traffic accident [
A 37-year-old man, while riding an electric mobile, collided with a bicycle from the opposite way and sustained multiple injuries. He was declared dead after rescue measures proved ineffectual. Forensic autopsy was performed the next day. On inspection, chest and abdomen were unremarkable, and several soft tissue injuries were found on other apartments of the body. Internal examination revealed no pathological lesions such as fractures and hemorrhage were detected on the chest wall or in the rib cage musculature. There was a rupture of soft tissue with slight hematocele around the spleen in the abdominal cavity. Pericardium was intact, with hematocele and clotted blood having a volume of 500 ml in the pericardial cavity. An irregular rupture measuring 0.5 cm × ventricular cavity deep was present on the right ventricle with multiple hemorrhagic regions surrounding. Multiple areas of bilateral cardiac muscle, especially the right side, were substituted by transmural fibrofatty tissue. The histopathologic result of the rupture showed the right ventricular wall was thinned severely owing to myocyte replacement by transmural fibrofatty infiltration and lesser amounts of fibrosis (
A 37-year-old man, with a history of drug abuse, died very quickly after fighting with others. The medicolegal autopsy showed there were 2 irregular contusions on the left chest, multiple contusions with overlying abrasions on the left chest wall, and 2 contusions on other apartments. Regions beside the midclavicular line showed the fracture of the left 6th rib, as well as surrounding muscular hemorrhage. The heart weighed 301 g, and on the left ventricular apex a full-thickness rupture of 0.7 cm with a hemorrhagic region surrounding was detected (
Firstly, cardiac rupture’s epidemiological characteristics must be taken into consideration. Cardiac rupture is the most severe form of blunt chest injury [
the heart and great vessels, and 7) the “hydraulic ram” effect in which sudden compression of abdominal and/or extremity veins forcibly distends the cardiac chambers [
Then, it is reasonable to observe microscopic morphological changes, so as to determine if there are any abnormalities in the heart. The complexity of cardiac structure and the variety of external forces make it hard to explain the various mechanisms of cardiac rupture, and especially when different mechanisms interact in a complex manner to produce the broad spectrum of blunt cardiac injuries. Meanwhile, it has been proved that a diseased heart is more susceptible to traumatic injury than a normal one. The diseased heart is more likely to rupture at the weak point of fragile myocardium like the areas of recent myocardial infarction [
It is also quick essential to deduce the way of the external force by grasping the information about the scenes and cases sufficiently. And other injuries associated with heart rupture, just like rib fractures, brain injury, contusions and etc, is also conducive to judge the magnitude level, the direction and the characteristic of the force applied on the body. Besides, judge if the external force can cause the rupture alone, or say if the locations, sizes and depths of the cardiac rupture conform to the external force or not. If not, forensic pathologists should define whether or not the dead have had old myocardial infarction (OMI), cardiomyopathy, fatty heart, cardiac valvular disease, or other pre-existent pathological changes heart diseases, and investigate the severity of them by a comprehensive anatomy and microscopic examination. But it is not to say the degree of injury determine its participation of death. It is noted that cardiac rupture may be produced by the compression of the chest or/and by the increased intrathoracic pressure transmitted from a stroke to the chest, even without visible marks of external injury [
Furthermore, cardiac rupture can also be a rare iatrogenic complication during cardio-pulmonary resuscitation (CPR) [
For those basic points, we present our analysis of the 2 cases. In Case 1, the micromorphologic changes of transmural fibrofatty replacement of the right ventricular free wall and the minimal or absent of the violence on the patient’s chest (no obvious signs of chest trauma) suggested arrhythmogenic right ventricular cardiomyopathy (ARVC) [
In case 1, we concluded that the patient was dead from cardiac tamponade by the cardiomyopathy of the right ventricle combining with right ventricular rupture, and the force was an assistant factor. In case 2, the death was mainly caused by the external force, which led to cardiac rupture and cardiac tamponade, with drug abuse and the cardiac pathological changes being considered as an assistant factor.
The work was partly supported by the Council of National Natural Science Foundation of China (81471819).
Qi Wang,Lingyun Yang,Yinming Zhang,Yao Yao,Haijun He,Zhenyuan Wang, (2016) Forensic-Pathological Analysis of Blunt Cardiac Rupture Involving the Relationship between Injury and Disease: 2 Cases Report and Review of the Literature. Forensic Medicine and Anatomy Research,04,23-28. doi: 10.4236/fmar.2016.42004