Cardiopulmonary resuscitation does not cause left ventricular rupture of the heart with acute myocardial infarction: a pathological analysis of 77 autopsy cases

doi:10.1016/S1344-6223(03)00002-6

Legal Medicine

Volume 5, Issue 1, March 2003, Pages 27-33

https://doi.org/10.1016/S1344-6223(03)00002-6 Get rights and content

Abstract

Cardiac rupture during acute myocardial infarction (AMI) is one of the most frequent causes of sudden cardiac death. However, some reports have indicated the possibility that the cardiac rupture during AMI may occur by external cardiac massage. We pathologically examined the hearts of 77 patients who died suddenly due to ventricular free wall rupture during AMI (51 men and 26 women; aged 47–94 years; mean age: 69.9 years). We divided the cases into two groups, 44 cases with and 33 cases without cardiopulmonary resuscitation (CPR), and compared the two groups with respect to 12 pathological items. There were no statistical differences in any of the investigated items between the two groups (P>0.05). In addition, mural thrombi were identified along the rupture tract in all cases. Moreover, they were more matured at the subendocardial zone than at the subepicardial or middle zone, irrespective of the groups. From the pathological findings, we concluded that the rupture of the left ventricle during AMI originates from the subendocardial region and precedes the external cardiac massage. Our present study strongly suggests that CPR does not cause the left ventricular rupture of the heart during AMI.

Introduction

Cardiac rupture during acute myocardial infarction (AMI) is one of the most frequent causes of sudden cardiac death [1], [2], [3], [4]. It has been suggested that external cardiac massage of infarcted areas may lead to left ventricular rupture. In fact, a few reports of left ventricular rupture with AMI following cardiopulmonary resuscitation (CPR) have been reported [5], [6], [7], although generally rupture occurs spontaneously. To our knowledge, there has been no pathological study comparing cases of cardiac rupture during AMI with CPR to those without CPR. In the present study, therefore, we pathologically compared cases of cardiac rupture during AMI with and those without CPR, and morphologically evaluated whether cardiac rupture in fact occurred as a result of cardiopulmonary resuscitation in these cases.

Section snippets

Materials

We pathologically examined 77 patients who died suddenly of ventricular free wall rupture during AMI (51 men and 26 women; aged 47–94 years; mean age: 69.9 years) at our institutes (60 cases) and at the Department of Legal Medicine, Kitasato University School of Medicine (17 cases) between March 1996 and February 1998.

Diagnosis of myocardial infarction was established based on macro- and microscopic findings of the affected myocardium and on the existence of coronary plaque disruption with

Results

No significant differences were found between the CPR and the NCPR group in any of the investigated items (see Table 1, Fig. 1, Fig. 2).

Discussion

Previous reports have suggested that CPR, particularly external cardiac massage, in patients with AMI can result in rupture of the left ventricle [5], [6], [7]. In the present study, we show that CPR for patients with AMI did not cause left ventricular rupture. The evidence that CPR did not produce left ventricular rupture through the infarcted area were as follows.

First, there were no morphological differences in the left ventricular free wall rupture through the infarcted area between the

Acknowledgements

The authors wish to express their deep appreciation to the medical examiners at Tokyo Medical Examiner's Office and Professor Katsuyoshi Kurihara, Department of Forensic Medicine, Kitasato University School of Medicine, for their kind permission in letting us examine their cases. We also wish to express gratitude to the medical technologists at Tokyo Medical Examiner's Office and our department for their excellent technical assistance. This study was supported in part by a Grant-in-Aid from the

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Cardiac rupture with intact pericardium: A report of four cases and short review of the literature
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Citation Excerpt :
Moreover, the CPR-related rupture usually occurs after cardiopulmonary arrest and the hemorrhaged blood is not clotted. This description is not only consistent with our experience from forensic practice but also reported by several studies [5,6]. The decedents who developed CPR-related cardiac rupture had other fatal diseases or trauma that can explain the cause of death.
Cardiac rupture with intact pericardium is a dangerous lesion due to high and rapid mortality. Its most common etiologies are blunt chest trauma and myocardial infarction. In forensic practice, this type of rupture can involve a complex relationship between trauma and cardiac disease, so clarifying the main cause of rupture is critical. Herein, we present four cases of cardiac rupture with intact pericardium, which were due to trauma, pathology or both. We propose several diagnostic pointers to analyze this uncommon lesion. Furthermore, the possibility of cardiac rupture induced by cardiopulmonary resuscitation should also be discriminated in such cases.
Complications of cardiopulmonary resuscitation in non-traumatic cases and factors affecting complications
2016, Egyptian Journal of Forensic Sciences
In this study, bodily injuries related to chest compression were examined in non-traumatic death cases that underwent autopsy. This study aimed to evaluate factors that can affect these injuries.
Data were collected retrospectively, and injuries related to chest compression during cardiopulmonary resuscitation were determined over a 10-year period. Age, gender and cause of death were determined, and when cardiopulmonary resuscitation was performed, cardiopulmonary resuscitation duration, intubation and the injury that occurred due to chest compression were also determined.
The study included data from 203 cases. The most frequent injuries were a single fracture in the left ribs (19.7%). Only the duration of cardiopulmonary resuscitation was determined to be associated with injuries. Ventricle rupture in 1 case and liver laceration in 2 cases were the most significant injuries.
It has been shown that during cardiopulmonary resuscitation, severe injuries can occur due to thoracic compression. Only a positive correlation with the duration of cardiopulmonary resuscitation was found in our study.
Prevalence of Type A Acute Aortic Dissection in Patients with Out-Of-Hospital Cardiopulmonary Arrest
2016, American Journal of Cardiology
Postmortem computed tomography (PMCT) has been recently reported to be useful for detecting causes of death in the emergency department. In this study, the incidence and causes of death of type A acute aortic dissection (AAD) were investigated in patients who experienced out-of-hospital cardiopulmonary arrest (OHCPA) using PMCT. PMCT or enhanced computed tomography was performed in 311 of 528 consecutive patients experiencing OHCPA. A total of 23 (7%) of 311 patients were diagnosed with type A AAD based on clinical courses and CT findings. Eighteen consecutive patients who did not experience OHCPA were diagnosed with type A AAD during the same period. Pre-hospital death was observed in 21 (51%) of 41 patients with type A AAD. Bloody pericardial effusion was observed more frequently in patients who experienced OHCPA with type A AAD than in those who did not experience OHCPA with type A AAD (91% vs 28%, respectively; p <0.05). In conclusion, the incidence of type A AAD was common (7%) in patients who experienced OHCPA, with a high rate of pre-hospital death. Aortic rupture to the intrapericardial space was considered the major cause of death in patients who experienced OHCPA with type A AAD.
Intra-thoracic injuries associated with cardiopulmonary resuscitation - Frequent and serious
2016, Resuscitation
The aim of the study was to evaluate prevalence, seriousness and risk factors of intra-thoracic injuries (ITI) injuries associated with CPR in non-survivors after out-of-hospital cardiac arrest.
This was a prospective forensic autopsy cohort study conducted in a single institution. Pathologists recorded autopsy data using standardized protocol which contained data from external and internal examination of the body focused on ITI.
In total, 80 persons were included in this study. CPR-associated injuries were found in 93.7% of cases; majority of injuries were skeletal chest fractures (rib fractures in 73.7%, sternal fractures in 66.3%). ITI were identified in 41.2% of cases. Contusion of at least one lung lobe was found in 31.2%, lung laceration in 2.5%, and hemothorax in 5.0% of cases. Transmural heart contusion was identified in 17.5% of cases; hemopericard on the grounds of right atrium rupture of aortic rupture was revealed in 8.7% of cases.
Risk factor analysis did not show any statistically significant correlation between ITI and any of general data (age, gender, BMI, cause of death, season of the year or location where the body was found) or CPR specifications (type and duration of CPR, manner of chest compressions). A strong correlation between ITI and skeletal chest fractures was proven.
ITI present frequent and serious complications of unsuccessful CPR. ITI could contribute to the death only provided the fact that ROSC had been achieved. Correct performance of chest compressions according to guidelines is the best way to avoid ITI.
Injuries associated with resuscitation - An overview
2015, Journal of Forensic and Legal Medicine
Citation Excerpt :
Thus, rupture of the right ventricle of the heart is believed to occur when there is increased pressure in the right side of the heart (for example due to outflow obstruction by pulmonary thromboembolus) or as a consequence of the application of an incorrect technique.60 It is considered that rupture of infarcted regions of the left ventricle does not occur due to resuscitation, but that the rupture of the infarct with resulting haemopericardium precedes application of chest compressions.61 However, rupture of areas of non-infarcted heart has been recorded46 and cases with small volumes (less than 200 ml) of non-clotted blood in the pericardial sac in association with a ruptured myocardial infarction have been encountered at this centre that suggest the rupture was caused by the external cardiac massage.
External cardiopulmonary resuscitation is a potentially lifesaving intervention aimed at preserving the cerebral function of a person in cardiac arrest. However, certain injuries can be caused by the various techniques employed. Although these are seldom consequential, they may complicate the forensic evaluation of cases. Fractures of the ribs and sternum are the most common internal injuries and are frequently acknowledged as a consequence of resuscitation. Nonethlesss, the recognition that less common fractures such as of the larynx or injuries involving the stomach, spleen, heart and liver can occur due to resuscitation will assist the forensic examiner assess the significance of these findings when they present in cases of sudden death.
CPR-related injuries after manual or mechanical chest compressions with the LUCAS™ device: A multicentre study of victims after unsuccessful resuscitation
2014, Resuscitation
Citation Excerpt :
Injuries to the spleen are considered even more uncommon and no patient with spleen injury was found in this study. Ruptures of the heart have been reported to occur due to CPR but this has been questioned by several studies stating that the ruptures probably occurred prior to CPR.33–36 The tamponades found in this study were considered to come either from cardiac ruptures due to myocardial infarcts or from aortic dissections.
The reported incidence of injuries due to cardiopulmonary resuscitation using manual chest compressions (manual CPR) varies greatly. Our aim was to elucidate the incidence of CPR-related injuries by manual chest compressions compared to mechanical chest compressions with the LUCAS device (mechanical CPR) in non-survivors after out-of-hospital cardiac arrest.
In this prospective multicentre trial, including 222 patients (83 manual CPR/139 mechanical CPR), autopsies were conducted after unsuccessful CPR and the results were evaluated according to a specified protocol.
Among the patients included, 75.9% in the manual CPR group and 91.4% in the mechanical CPR group (p = 0.002) displayed CPR-related injuries. Sternal fractures were present in 54.2% of the patients in the manual CPR group and in 58.3% in the mechanical CPR group (p = 0.56). Of the patients in the manual CPR group, there were 64.6% with at least one rib fracture versus 78.8% in the mechanical CPR group (p = 0.02). The median number of rib fractures among patients with rib fractures was 7 in the manual CPR group and 6 in the mechanical CPR group. No CPR-related injury was considered to be the cause of death.
In patients with unsuccessful CPR after out-of-hospital cardiac arrest, rib fractures were more frequent after mechanical CPR but there was no difference in the incidence of sternal fractures. No injury was deemed fatal by the pathologist.

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Cardiopulmonary resuscitation does not cause left ventricular rupture of the heart with acute myocardial infarction: a pathological analysis of 77 autopsy cases

Abstract

Introduction

Section snippets

Materials

Results

Discussion

Acknowledgements

Am J Cardiol

Hum Pathol

Chest

Am Heart J

Chest

Cardiac rupture due to myocardial infarction: a statistical study of autopsy cases in Tokyo Medical Examiner's Office

Res Pract Forensic Med

Practical cardiovascular pathology

Cardiopulmonary complications of external cardiac massage

Hawaii Med J

Cardiac laceration and pericardial tamponade due to cardiopulmonary resuscitation after myocardial infarction

J Forensic Sci

Cardiac tamponade. A study of 50 hearts

Eur J Cardiol

The speed of healing of myocardial infarction. A study of the pathologic anatomy in seventy-two cases

Am Heart J

The ageing of cardiac infarcts, and its influence on cardiac rupture

Br Heart J