[Echocardiographic documentation of the instant of cardiac rupture: a case report]

The instant of cardiac rupture was initially recorded using two-dimensional echocardiography in a patient with acute myocardial infarction. This 70-year-old woman was admitted to our hospital because of chest pain lasting for six hours. The admission electrocardiogram showed Q waves and S-T segment elevations in leads I, aVL, and V4-6. Two-dimensional echocardiography revealed hypokinesis in the middle and apical portions of the anterior septum and hyperkinesis in the basal portion of the anterior septum and the posterior wall. When the patient suddenly lost consciousness, echocardiography detected a rapidly developing pericardial effusion, which filled the pericardial sac within 13 sec. A myocardial tear was recognized at the apex of the left ventricle between portions of the hypokinesis and hyperkinesis. A simultaneously-recorded electrocardiogram showed sinus rhythm (84/min) which did not change at the moment of rupture and lasted further for 15 sec until a sudden alteration to sinus bradycardia (46/min) occurred. Cardio-pulmonary resuscitation was unsuccessful and the patient died. This is the first such case in the medical literature in which the instant of cardiac rupture was recorded. Detailed reviews of the video tapes revealed that rapid accumulation of pericardial fluid occurred, followed by transient sinus bradycardia, most likely due to vagal reflex to the stretched pericardium.