Table 3.

Cardiac pathological characteristics and immunohistochemical results

Anatomic location	Pathologic feature	Immunohistochemical result	Perforation site	Complication	Probable cause of death	Ref.
Anterior left ventricle	Transmural necrosis, ventricular septal perforation (2.0 cm)	CD68 + macrophages densely packed, IL-1β highly expressed	Apical interventricular septum	Acute left heart failure, ventricular fibrillation	Cardiogenic shock	[20,21]
Basal part of the ventricular septum	Myocardial rupture with hematoma	Neutrophil infiltration, C3d complement deposition (++)	Near aortic valve at basal part	Third-degree atrioventricular block	Cardiac arrest	[22,23]
Anterior right ventricle	Necrosis extends to right ventricle, perforation slit-like	CD3 + T cell infiltration, IFN-γ positive	Anterior interventricular septum	Right heart failure, hepatic congestion	Multi - organ failure	[120,121]
Lateral left ventricle	Old infarct area calcified, fresh perforation (0.8 cm)	CD163 + M2 - type macrophages predominant, TGF-β highly expressed	Lateral edge of interventricular septum	Wall thrombus, cerebral embolism	Large - area cerebral infarction	[122,123]
Middle of the ventricular septum	Necrosis with abscess formation	CD15 + neutrophils aggregated, Gram-positive bacteria detected	Middle of the ventricular septum	Septic shock, infective endocarditis	Sepsis with DIC	[23,124]
Inferior left ventricle	Transmural necrosis with pericarditis	CD20 + B lymphocyte infiltration, focal IL-10 expression	Posterior - inferior part of interventricular septum	Cardiac tamponade, cardiac rupture	Acute cardiac tamponade	[125,126]
Papillary muscle root	Papillary muscle rupture with mitral valve prolapse	CD31 + neovessel growth, VEGF highly expressed	Posterior papillary muscle attachment area of interventricular septum	Acute mitral regurgitation, pulmonary edema	Acute pulmonary edema asphyxia	[127,128]
Apical left ventricle	Ventricular aneurysm formation, thrombus at perforation edge	CD68 + /CD206 + M2 - type macrophage polarization	Apical interventricular septum	Peripheral artery embolism (mesenteric)	Intestinal necrosis leading to septic shock	[129,130]
Upper part of the ventricular septum	Perforation with aortic valve ring tear	CD4 + helper T cell infiltration, HLA-DR overexpressed	Upper part of interventricular septum near aortic valve	Aortic valve regurgitation, coronary artery dissection	Acute circulatory collapse	[131,132]
Right ventricular outflow tract	Necrosis involving pulmonary valve	CD8 + cytotoxic T cell infiltration, PD-L1 negative in perforation area	Perforation in outflow tract of interventricular septum	Pulmonary hypertension, right ventricular failure	Acute right heart failure	[133,134]
Posterior left ventricle	Transmural necrosis extending to AV groove	IgG/IgM immune complex deposition, C1q positive	Posterior - basal part of interventricular septum	Complete atrioventricular block	Asystole syndrome	[135,136]
Anterior edge of the ventricular septum	Multiple small perforations (3 sites)	CD66b + NETs formed	Anterior 1/3 of interventricular septum	DIC, micro thromboembolism	Multi - organ microinfarction	[135,137]
Basal left ventricle	Transmural necrosis with ventricular wall rupture	TNF-α/IL-6 double - positive cells diffuse	Basal part of interventricular septum	Mediastinal hematoma, pericardial effusion	Hemorrhagic shock	[120,122]
Posterior right ventricle	Necrosis with fat infiltration	CD34 + microvessel density increased, Ang-2 highly expressed	Posterior - inferior part of interventricular septum	Pulmonary embolism, right atrial enlargement	Acute pulmonary embolism	[138,139]
Anterior interventricular septum	Ventricular aneurysm with mural thrombus	CD47 highly expressed (anti-phagocytosis signal), fibrosis at perforation edge	Middle of anterior interventricular septum	Thrombus detachment causing renal infarction	Acute renal failure	[130,140]
Junction of the septum and right ventricle	Granulation tissue growth in necrotic area	CD45RO + memory T cell infiltration, IL-17A positive in perforation area	Right ventricular face of interventricular septum	Refractory ventricular tachycardia	Electrical storm	[141,142]
Posterolateral left ventricle	Transmural necrosis involving posterior leaflet of mitral valve	Mixed CD68 + macrophage and CD3 + T cell infiltration	Posterior papillary muscle area of interventricular septum	Acute mitral regurgitation, pulmonary edema	Respiratory failure	[123,125]
Apical part of the septum	Perforation with left ventricular apical thrombus	CD14 + monocyte aggregation, MMP - 9 overexpression in perforation area	Apical interventricular septum	Cerebral embolism, lower limb artery embolism	Brainstem infarction	[22,143]
Right ventricular septal part	Necrosis extending to tricuspid valve ring	CD79a + B cell infiltration, IgA deposition	Right side of interventricular septum	Tricuspid regurgitation, hepatic and renal failure	Hepatorenal syndrome	[144,145]
Anterolateral left ventricle	Transmural necrosis with epicarditis	CD123 + plasmacytoid dendritic cell infiltration, IFN-α positive in perforation area	Anterolateral edge of interventricular septum	Pericarditis, pleural effusion	Cardiac tamponade	[122,123]
Middle of the septum	Necrotic area with eosinophilic infiltration	CD117 + mast cell activation, histamine release in perforation area	Middle 1/3 of interventricular septum	Anaphylactic shock, bronchospasm	Asphyxia	[124,146]
Posterior basal left ventricle	Old calcified lesion with fresh perforation	CD68 + macrophages and CD20 + B cell colocalization	Posterior - basal part of interventricular septum	Splenic infarction, sepsis	Septic cardiomyopathy	[147,148]
Apical right ventricle	Necrosis with fatty degeneration	CD36 + foam cell aggregation, ox - LDL positive	Apical part of right ventricle	Pulmonary infarction, ARDS	Respiratory failure with right heart failure	[149,150]
Anterior part of the left ventricle interventricular septum	Transmural necrosis with coronary artery fistula	CD144 + endothelial injury marker, VWF highly expressed in perforation area	Anterior interventricular septum near left anterior descending artery	Coronary artery - ventricular fistula, myocardial steal	Refractory hypotension	[151,152]
Junction of the septum and left ventricle	Necrosis with lymphatic dilation	CD68 + macrophages engulfing hemosiderin	Left ventricular face of interventricular septum	Chylothorax, protein - losing enteropathy	Hypoproteinemia causing multi - organ edema	[153,154]
Extensive anterior left ventricle	Large - area necrosis (> 40% left ventricle)	CD163 + M2 macrophages predominant, IL-10 highly expressed in perforation area	Anterior and middle parts of interventricular septum	Cardiogenic shock, lactic acidosis	Metabolic acidosis causing cardiac arrest	[155,156]
Posterior upper part of the septum	Perforation with chordae tendineae rupture	Mixed CD68 + macrophage and CD15 + neutrophil infiltration	Posterior upper part of interventricular septum near mitral valve	Acute mitral valve flail, pulmonary edema	ARDS	[124,157]
Free wall of the right ventricle	Necrosis with epicardial hemorrhage	CD11b + myeloid cell infiltration, MPO positive in perforation area	Free wall of right ventricle	Pericardial effusion, cardiac tamponade	Acute circulatory failure	[158,159]
Posterolateral left ventricle	Transmural necrosis involving left atrium	CD68 + macrophage polarization (M1 predominant), TNF-α/IL-1β co - expression in perforation area	Posterolateral edge of interventricular septum	Atrial fibrillation, left atrial thrombus	Cerebral embolism with brain herniation	[155,160]
Whole layer of the septum	Multiple perforations (5 sites) with myocardial dissolution	CD4+/CD8+ T cell ratio inverted, Fas/FasL highly expressed in perforation area	Anterior, middle, and posterior parts of interventricular septum	Whole - heart failure, hyperkalemia	Electromechanical dissociation	[161,162]

DIC: Disseminated intravascular coagulation; VEGF: Vascular endothelial growth factor; HLA-DR: Human leukocyte antigen-DR; PD-L1: Programmed death-ligand 1; AV: Atria and ventricles; NETs: Neutrophil extracellular traps; TNF-α: Tumor necrosis factor-α; IL: Interleukin; MMP-9: Matrix metalloproteinase-9; IgA: Immunoglobulin A; ox-LDL: Oxidized low-density lipoprotein; VWF: Von Willebrand factor; ARDS: Acute respiratory distress syndrome; MPO: Myeloperoxidase.