Abstract
Left ventricular free wall rupture (LVFWR) is a now exceedingly rare, but potentially
life-threatening complication of myocardial infarction (MI) that can present as cardiac
tamponade and/or cardiogenic shock. Seen more commonly in days prior to reperfusion
as a sequela of complicated transmural MI, LVFWR has seen a decline in incidence in
the age of primary angioplasty for MI. It is now a rarely encountered phenomenon usually
associated with late-presenting MI. We present a case of LVFWR following a late-presenting
MI with severe shock and cardiac tamponade. Initial transthoracic echocardiography
with contrast showed pericardial effusion with cardiac tamponade and no overt signs
of rupture. Computed tomography angiography of the chest and Transesophageal echocardiography
did not demonstrate aortic dissection. Pericardiocentesis of hemorrhagic effusion
transiently improved hemodynamics but was followed by rapid cardiac decline and death.
Subsequent necropsy showed left ventricular wall rupture with focal fibrosis in the
distal left ventricular wall, consistent with a remote infarction, along with a large
pericardial clot. This case underscores the diagnostic challenges of LVFWR, particularly
when imaging is inconclusive in hemodynamically unstable patients. Despite technological
advances, clinical suspicion remains paramount, especially in patients presenting
with shock and hemorrhagic pericardial effusion. Surgical intervention remains the
definitive therapy.
Keywords
hemorrhagic pericardial effusion - cardiac tamponade - free wall rupture - aortic
dissection - cardiogenic shock - case report
