Unexpected rupture of the left ventricular free wall in the echo-lab

Left ventricular free wall rupture is an uncommon but catastrophic event following myocardial infarction, and considered the second leading cause of death in acute myocardial infarct. Different types of rupture exist from acute to sub acute types, but prognosis is usually poor. Early recognition and aggressive treatment is recommended.

We present a case of a 75-year-old man who was referred to our echo-lab for an out patient evaluation because of 1-week duration of worsening of chest pain. Standard transthoracic echocardiography showed hypokinesia in the apical portion of the anterior wall and basal portion of the inferior wall. The patient complained of shortness of breath immediately after the conclusion of the exam, and soon afterward became unconscious. Renewed echocardiography approximately 1 min after syncope displayed a newly developed echo-lucent rim around the heart consistent with left ventricular free wall rupture. Resuscitation was performed followed by attempts to evacuate the blood by needle aspiration, which failed. Open pericardiocentesis stabilised the patient until surgery could be performed. The patient survived and could be discharged 2 weeks later.

This case highlights the fact that rapid and accurate diagnosis is essential if patients with left ventricular free wall rupture are to survive.