SUBACUTE LEFT VENTRICULAR FREE WALL RUPTURE

Abstract

Left ventricular free wall rupture is a rare and catastrophic mechanical complication after myocardial infarction. Surgical exploration and rupture repair is the definitive diagnostic and therapeutic procedure. We report the case of a 69–year–old male with no significant cardiac history, admitted to our department for an inferior–lateral ST–segment elevation myocardial infarction, manifesting as chest pain and subsequent loss of consciousness. On admission, the patient was hemodynamically stable (BP: 100/60 mmHg; HR: 127 bpm). Urgent coronary angiography indicated acute thrombotic occlusion of the circumflex artery’s OM branch, necessitating percutaneous coronary intervention on the affected vessel. Echocardiography identified akinesia in the inferior septal, inferior and inferior–lateral walls, along with pericardial effusion with hemorrhagic density (3.7 cm at the atrioventricular junction in subcostal projection), causing marked biatrial compression and significant dilation of the suprahepatic venous system. Urgent angio–CT ruled out aortic dissection or ventricular wall rupture. However, due to deteriorating hemodynamic conditions, emergency median sternotomy with pericardial toilet was performed, revealing no evident breaches in the cardiac walls and targeted echocardiography revealed a mild circumferential pericardial effusion (1.1 cm). Following amino and inotropic support, the patient’s clinical conditions stabilized. On the fifteenth day post–acute event, a new syncopal episode occurred (BP: 110/70 mmHg, HR 90 bpm). Echocardiography showed an organized clot compressing right atrium and right ventricular inflow tract during the systo–diastolic phase. Angio–CT revealed a voluminous blood collection at the left ventricular apex, supplied by iodinated contrast, suggesting a probable rupture of the postero–inferior cardiac wall. Consequently, a second emergency median sternotomy exposed profuse bleeding from a left ventricular wall pseudoaneurysm. After initiating extracorporeal circulation, the clot was evacuated and a 1 cm breach in the left ventricular inferior wall was sutured. Considering recent STEMI and the need for high doses of inotropic support, an intra–aortic balloon pump was positioned.Post–procedural echocardiography confirmed successful repair with no subvalvular mitral apparatus alterations. Unfortunately, after approximately 12 hours of intensive monitoring, the patient succumbed to refractory cardiogenic shock despite therapy.