Successful conservative treatment for left ventricular free wall rupture after acute myocardial infarction

Abstract

Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days.

Keywords: Acute myocardial infarction (AMI); Cardiac tamponade; Cardiogenic shock; Conservative treatment; Left ventricular free wall rupture (LVFWR).

Fig. 1

12-lead ECG. HR 111/min regular, I aVL V5–V6 ST elevation, V1–V3 ST depression, III V4–V6 negative T wave, suggesting posterior wall STEMI

Fig. 2

Bedside echocardiography (immediately after transportation). Bedside echocardiography immediately after transfer (A) showed an echo-free space of approximately 5–8 mm, suggesting a clot around the posterior wall (triangle). Twenty-five minutes later (B), a high bright echo-free space was observed that rapidly expanded to more than 30 mm in the anterior right ventricle (triangle).

Fig. 3

Coronary angiography and left ventriculography. No stenosis was observed in the right coronary artery, and 100% occlusion was observed in the left circumflex coronary artery just after the bifurcation of the obtuse marginal branch (A) (B). In the LVG, LAO view confirmed the oozing of the contrast agent into the pericardium at the posterior wall region (C) (arrow)

Fig. 4

Contrast-enhanced MRI image on the 33. T2WI showed high signal mainly subintima (partially penetrating) from the lateral wall to the posterior wall, which coincides with the posterior aspect of the heart (triangle)