Ventricular silent rupture leading to sudden death: Navigating diagnostic challenges in a resource-constraint setting

Key Clinical MessageVentricular myocardial rupture is a rare complication of myocardial infarction. It occurs within hours to weeks after an infarction. Mortality is high. Antemortem diagnosis is a challenge in low-resource settings, leading to potential misdiagnosis.AbstractLeft ventricular myocardial rupture is a potentially fatal yet common complication in acute myocardial infarction patients. Rupture can occur as early as hours after an infarction. However, rupture may also occur later in the first week in the setting of myocardial necrosis and neutrophilic infiltration. Patients may survive several days to weeks before rupture occurs, and cardiac tamponade may present subacutely with a slow or repetitive clinical course. Sudden death can be attributed to ventricular rupture, more commonly during this time frame. Myocardial rupture can also occur as a result of trauma, infections, or cancer. Mortality is exceedingly high if surgical intervention is delayed. In most patients, myocardial rupture manifests as a catastrophic event within days of a first, small, uncomplicated acute myocardial infarction. Acute onset of shortness of breath, chest pain, shock, diaphoresis, unexplained emesis, cool and clammy skin, and syncope may herald the onset of ventricular septal rupture after acute myocardial infarction. Sudden death from myocardial rupture during acute myocardial infarction in patients with no apparent previous symptoms of myocardial ischemia represents a challenge for medical examiners, law enforcement officers, and society as a whole. An autopsy is critical for establishing the cause of death. We present the case of a 54-year-old male whose body was found beside the road after a trivial quarrel a day before. Further medical information about the deceased was not available. The preliminary cause of death was presumed to be traumatic. No evidence of trauma was seen during the autopsy. Massive pericardial blood collection compressing the heart and concealed left ventricular myocardial rupture were noted. Histopathological examination of the heart demonstrated myocardial infarction with a tear associated with bleeding that was contained in the pericardial sac. We ruled cardiac tamponade as the cause of death due to an infarcted myocardial rupture. Antemortem diagnosis of myocardial rupture can be challenging in low-resource settings, leading to potential misdiagnosis and negative impacts such as community conflicts. image