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Egyptian Journal of Forensic Sciences (2016) xxx, xxx–xxx

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Egyptian Journal of Forensic Sciences
journal homepage: http://www.journals.elsevier.com/egyptian-journal-of-forensic-sciences

CASE REPORT

Sudden death due to lethal strangulation of heart
by congenital partial pericardium
Manoj Bhausaheb Parchake a, Harish Pathak a, Sunil Vidhate a,
Rajesh Sukhadeve a, Nilesh Tumram b,*, Ravi Kamble a
a
Department of Forensic Medicine, Seth Gordhandas Sunderdas Medical College & King Edward Memorial Hospital,
Parel, Mumbai, India
b
Department of Forensic Medicine, Indira Gandhi Government Medical College, Nagpur, India

Received 10 December 2015; revised 31 May 2016; accepted 16 June 2016

KEYWORDS
Forensic sciences;
Forensic pathology;
Strangulation heart;
Congenital defect;
Pericardium

Abstract Cases of strangulation of heart are usually seen in post-operative heart surgery. However
such strangulation of heart can occur due to defect in pericardium. Here, we report a case of 32 year
old male who had complaint of chest pain while working on a building construction site. He had
previous episodes of intermittent chest pain which remained undiagnosed. On post-mortem
examination, it was observed that the deceased had defect in pericardium with bilateral absence
of pericardial sac. In absence of any previous surgical record it was found to be of congenital in
nature. Such absence of pericardial sac may remain dormant and can aggravate in situations like
stress which laid to constriction of pericardial sac to the ventricular wall leading to blockage of
heart vessels causing sudden stoppage of circulation to heart muscle itself. On post-mortem
examination opinion as to the cause of death was given as strangulation of heart due to bilateral
congenital partial pericardium. Such type of case is reported for its rarity.
Ó 2016 The International Association of Law and Forensic Sciences (IALFS). Production and hosting by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction
Strangulation (other than the act of strangling) means
constriction of a body part so as to cut off the flow of blood
or another fluid. Strangulation of heart is constriction of heart
by the edge of any defect in the pericardial wall causing
herniation of the heart appendages. A case of strangulation
* Corresponding author at: Department of Forensic Medicine,
Indira Gandhi Government Medical College, Nagpur 440018, India.
E-mail address: ntumram@rediffmail.com (N. Tumram).
Peer review under responsibility of The International Association of
Law and Forensic Sciences (IALFS).

of heart is very rare and mostly seen in post-operative heart
surgery in adults. Sudden death has been recognized to cardiac
strangulation or connected with other lesion such as congenital
heart disease.1–3 Congenital pericardial sac absence is an
uncommon incidence and computerized tomography
angiography (CTA) of the chest confirmed this rare entity estimated to occur in one in 10,000–14,000 people.4 Pericardial
absence is classified as a left or right defect. It is secondarily
being divided as total or partial. A majority of pericardial
defect is by far left-sided, with left total defects more common
than the left partial defects. Right-sided and bilateral absence
has not often been reported.5

http://dx.doi.org/10.1016/j.ejfs.2016.06.002
2090-536X Ó 2016 The International Association of Law and Forensic Sciences (IALFS). Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Parchake MB et al. Sudden death due to lethal strangulation of heart by congenital partial pericardium, Egypt J Forensic Sci (2016),
http://dx.doi.org/10.1016/j.ejfs.2016.06.002

2. Figure 3 Infiltration of neutrophils in the constricted area of myocardium suggesting recent ischemia. Similarly.ejfs. 3).7 However. He was brought to our hospital where he was declared brought in dead condition. There is evidence of luminal narrowing with evidence of reddish thrombus at the level of constriction. and was absent over the entire LV. some subjects may present with symptoms of atypical chest pain. 2). Rim of pericardial sac was present 4 cm above the apex encircling the heart. Pericardial sac was absent bilaterally on the lower half of the heart.8 On clinical examination there are signs suggestive of laterally displaced apex or absent apical impulse and Please cite this article in press as: Parchake MB et al. Discussion Figure 1 Pericardial sac was present 4 cm above the apex encircling the heart. luminal narrowing of left anterior descending artery with evidence of thrombus at the level of constriction. 4. There was evidence of impression of rim of the pericardial sac over myocardial wall. indicating the absence of pericardium at this level. No other abnormality detected on gross and microscopic examination. His body length was 161 cm. there was evidence of a compression of ascending aorta 2. dyspnea and palpitations. Parchake et al. On the day of incidence while working on a building site he suddenly felt chest pain and collapsed.2 M. but had intermittent chest pain. No evidence of oozing of fluid from natural orifices.org/10. He had no significant family history.06. 3. There was evidence of Figure 2 Evidence of impression of rim of the pericardial sac over myocardial wall. and body weight 64 kg. Left lung was visible between the aorta and pulmonary artery. Right side of partial pericardium was adherent to the diaphragm. 1). Following post-mortem examination opinion as to the cause of death was given as strangulation of heart due to partial pericardium in a case of heart in abnormal position. There was no significant cardiac history. Egypt J Forensic Sci (2016). the deceased was averagely built and nourished. The heart was dissected by inflow-outflow method.2016.B.002 .6 Such patients have very non specific clinical presentation and most are detected incidentally. The deceased was a construction laborer at a local building site. Weight of heart was 320 gm. Circumference of pericardium sac was 21 cm (Fig. On cut section there was evidence of a compression of right and left ventricle at the level of constriction. Case report A 31 year old male had a history of chest pain. http://dx.doi. Congenital absence of pericardium can be termed as a range of congenital pericardial defect from a small foramen in the pericardium to a complete absence of the entire pericardium. On opening the thoracic cavity there was evidence of abnormal position of the heart. Autopsy findings On external examination.1016/j. No evidence of previous surgical scar present over chest.5 cm above the aortic valve by abnormal position of heart and thick pericardium. for which he was never admitted in a hospital. indicating a total left absence of pericardium (Fig. The pericardium was visible only overlying the base and middle portions of the right ventricle. Sudden death due to lethal strangulation of heart by congenital partial pericardium. Histopathological examination revealed recent signs of ischemia in the form of infiltration of neutrophils in the constricted area of myocardium (Fig. The position of the heart was leftward and the apex was situated posteriorly.

In this case strangulation of the heart and dilatation of the left ventricle or left ventricular hypertrophy are acting their force on coronary with opposite direction.Death due to strangulation of heart by congenital partial pericardium systolic murmurs and clicks of undetermined origin.12 Chest wall abnormalities have also been explained. Greenberg S. Roy L.104:1447–8. is suspended by its caudal attachments. Perez lozada JC. Circulation 2001. 5. tetralogy of Fallot and pulmonary sequestrations). Congenital absence of the pericardium presenting as acute myocardial necrosis.9 Some of the cases may show complications related to the defect. The pericardial rim caused constriction of the ventricle. Egypt J Forensic Sci (2016). first diagonal branch.06. Sudden death due to lethal strangulation of heart by congenital partial pericardium. Brulotte Staeve. 4. Razdan R. The assumed etiology of a pericardial defect is the premature atrophy of the left common cardinal vein (duct of Cuvier). This can result in complete compression of the ascending aorta resulting in dilation of the left ventricle or left ventricular hypertrophy causing complete obstruction of the coronary arteries and myocardial ischemia and death. Can J Cardiol 2007. Van Ardell Glen S. it was mostly seen in cases of post cardiac surgery. Right-sided and bilateral absence has infrequently been reported. http://dx.doi. Crummy AB. Conclusion Congenital bilateral partial pericardium can cause serious complications such as strangulation and herniation of heart and it can also be associated with abnormal position of heart. Chest 1993.11 The adult heart. The person with such issue if being involved in laborious works like in construction site can lead to stress on heart.7:271–86. diagnosis and management. A majority of pericardial defect is by far left-sided.104:977–8. Nasser WK. with left total defects more frequently than the left partial defects. 8. A proper diagnosis and treatment should be carried out in such type of cases. Chest 1975. Fowler MS. Ganguly SN. Saito10 found a 4 year-old boy with congenital partial defect of the left pericardium who presented with myocardial infarction and died of incarceration of the left ventricle.org/10. and the distal heart is a free-moving pendulum. like that of ventricular herniation. Ann Thorac Surg 2000. Isolated congenital absence of the pericardium: clinical presentation. coronary artery compression by the edge of pericardial defect. marked change in cardiac position with changing patient position on the examination table (cardioptosis) and with the cardiac cycle (swinging heart). Congenital absence of the pericardium. This second hypothesis is supported by Nguyen16 who observed that on catheritization in patients of congenital partial pericardium there was 3 evidence of dynamic complete compression of the mid-left anterior descending artery (LAD). resulting in complete obstruction of coronaries at the rim of partial pericardium resulting in myocardial ischemia and death. 7. position of the heart changes frequently. Such defects can cause sudden deaths without any significant signs and symptoms. Congenital diseases of the pericardium. Congenital pericardial defect associated with tetralogy of fallot herniation of normal lung into the pericardial cavity. Pericardial defects are rare. Munk Mare-David.1016/j.69:1209–15. atrial septal defect.5 These include strange echocardiographic windows. Conn Med 2009. torsion of great vessels secondary to increased cardiac mobility. which weighs an average of 350 g. While performing surgeries. In adults. 2. 6. They are linked with other congenital abnormalities in 30–50% of patients.29:132–5. and mid-circumflex arteries during diastole. Karakurt14 and Puvabanditsin15 reported death due to strangulation of hearts in infants. Cardiovasc Clin 1976. The resulting reduced blood supply to the left pleuropericardial membrane results in pericardial agenesis. Daniels Curt J. bronchogenic cysts. unnecessary pericardial defect should be avoided and pericardial defect if produced should be closed so that cardiac herniation and strangulation should be prevented.2016. This causes increase in pumping action and constriction of herniated part of heart by the rim of pericardial sac and subsequent compression of aorta resulting in myocardial infarction. Hipoma FA.23(11):909–12. Echocardiographic findings are also related to cardiac levoposition and increased mobility within the chest cavity. Strangulation of the left atria appendage through a congenital partial pericardial defect. Ohshima H. Roy Louis.002 . Katz Steven E. Larose Eric. Ethical approval Necessary ethical approval was obtained from the institute ethics committee. Congenital absence of the pericardium presenting as acute myocardial necrosis.ejfs.10 incarceration of the myocardium (commonly of left atrial appendage). Pericardial absence is classified as a left or right defect and further divided secondarily as being total or partial.73 (10):585–8.3 Ervin reported a case of 28 year old adult death due to strangulation of left atrium appendages through congenital partial pericardium defect. 3. (1) The heart has the ability to adapt to any critical condition like that of pericardial defects right from birth. 5. two possible hypotheses for causing death can be explained. 9. Can J Cardiol 2007.2 In the present case there was ventricular herniation of the heart from the congenital partial pericardial defect over the ventricles. Gatzoulis Michael A. Congenital complete absence of pericardium mimicking myocardial infarction: a case report and literature review. which resolved during systole.67(3):354–5. In the present case. (2) Due to abnormal position of the heart and partial pericardium. Robin E.13 Strangulation of heart was very rarely reported in the literature. mainly cardiac and pulmonary in nature (patent ductus arteriosus. et al. Brulotte S. Conflict of interest None declared. Takeuchi H. Circulation 1964. Larose E. et al. Raman Subha V. Yamaguchi T. Please cite this article in press as: Parchake MB et al. There is one reported case of a 14 year old boy who died of cardiac strangulation due to herniation of the left ventricle through the acquired pericardial defect which had been made 9 years before.23(11):909–12. References 1. et al. Funding None. Late cardiac strangulation due to iatrogenic pericardial defect.

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