Differentiating Post-myocardial Infarction Left Ventricular Free Wall Rupture from Cardiopulmonary Resuscitation-induced Cardiac Injury: A Forensic Autopsy Case Series

Abstract

Left ventricular free wall rupture (LVFWR) is a rare but catastrophic complication of acute myocardial infarction and poses a significant diagnostic challenge in medicolegal autopsy practice when cardiopulmonary resuscitation (CPR) has been administered prior to death. Both natural rupture and CPR-induced cardiac injury may present with haemopericardium and ventricular wall tears, leading to potential misinterpretation. This retrospective case series analyses three sudden death cases subjected to medicolegal autopsy, all of whom underwent CPR prior to being declared dead on arrival. Comprehensive gross cardiac examination, coronary artery dissection, histopathology, and evaluation for resuscitation-related skeletal injuries were performed. The decedents, aged 50–69 years, demonstrated large-volume haemopericardium with significant clot formation, irregular tears measuring 1.5–2.5 cm over the posterolateral wall of the left ventricle, and severe coronary atherosclerosis. Histopathology consistently revealed features of acute myocardial infarction. No rib or sternal fractures were identified in any case. The constellation of tear location, volume and nature of haemopericardium, absence of skeletal trauma, and histological evidence of infarction supported a diagnosis of natural LVFWR rather than CPR-induced cardiac injury. Recognition of these distinguishing features is crucial for accurate interpretation of cardiac findings during medicolegal autopsy.