Subacute left ventricle free wall rupture after acute myocardial infarction: awareness of the clinical signs and early use of echocardiography may be life-saving

Abstract

Left ventricular free wall rupture (LVFWR) is a fearful complication of acute myocardial infarction in which a swift diagnosis and emergency surgery can be crucial for successful treatment. Because a significant number of cases occur subacutely, clinicians should be aware of the risk factors, clinical features and diagnostic criteria of this complication. We report the case of a 69 year-old man in whom a subacute left ventricular free wall rupture (LVFWR) was diagnosed 7 days after an inferior myocardial infarction with late reperfusion therapy. An asymptomatic 3 to 5 mm saddle-shaped ST-segment elevation in anterior and lateral leads, detected on a routine ECG, led to an urgent bedside echocardiogram which showed basal inferior-wall akinesis, a small echodense pericardial effusion and a canalicular tract from endo to pericardium, along the interface between the necrotic and normal contracting myocardium, trough which power-Doppler examination suggested blood crossing the myocardial wall. A cardiac MRI further reinforced the possibility of contained LVFWR and a surgical procedure was undertaken, confirming the diagnosis and allowing the successful repair of the myocardial tear. This case illustrates that subacute LVFWR provides an opportunity for intervention. Recognition of the diversity of presentation and prompt use of echocardiography may be life-saving.

Figure 1

Surface 12-lead ECG on day 7 after the first episode of chest pain showing inferior Q-waves, "saddle-shaped" ST segment elevation and PR segment depression.

Figure 2

2D-Echo: apical four-chamber view showing a small global echodense pericardial effusion.

Figure 3

2D-Echo: apical two-chamber (A) and parasternal short axis (B) views showing a myocardial tear in the left ventricular inferior wall.

Figure 4

2D-Echo: apical two-chamber view with Power-Doppler suggesting blood flow across the inferior myocardial wall.

Figure 5

Cardiac MRI in short (A) and long (B) axis views showing pericardial effusion (large arrows) and thinning and dissection of the left ventricular inferior wall (small arrows).