Subacute Left Ventricular Free-Wall Rupture After Thrombolysis: From Concealed Rupture on CT to Successful Surgical...

Background and Clinical Significance: Left ventricular free-wall rupture (LVFWR) is a rare but devastating mechanical complication of acute myocardial infarction (AMI), with reported in-hospital mortality approaching 90% without surgical intervention. Although its incidence has declined in the contemporary primary percutaneous coronary intervention (PCI) era, LVFWR remains an important cause of early post-infarction death, particularly after delayed reperfusion or fibrinolytic therapy. Subacute or contained "oozing" ruptures pose a unique diagnostic challenge because hemodynamic stability and nonspecific symptoms can mask the underlying catastrophe, and standard transthoracic echocardiography may fail to visualize a sealed defect. Contrast-enhanced cardiac computed tomography (CT) has emerged as a valuable adjunct in this setting, enabling early recognition and surgical planning. Case Presentation: We report a case of a 51-year-old male, a heavy smoker, with acute lateral ST-segment elevation myocardial infarction (STEMI) treated with thrombolysis at a referring hospital, followed by percutaneous coronary intervention (PCI) to the obtuse marginal branch. Despite reperfusion, he developed persistent pleuritic chest pain and a small pericardial effusion. Cardiac computed tomography (CT) demonstrated a contained (sealed) lateral-wall oozing-type left ventricular free-wall rupture (LVFWR) with thrombus sealing the defect. A multidisciplinary heart team initially opted for diligent observation with frequent echocardiography. Within the first 24 h, the pericardial effusion increased, and echocardiography showed circumferential effusion with lateral wall thickening and hematoma, prompting emergent sternotomy. Intraoperatively, a large posterolateral infarct with an oozing-type LV free-wall rupture was identified. Surgical repair was performed using interrupted pledgeted sutures, native pericardial patch, BioGlue, and an overlying Teflon patch, with intra-aortic balloon pump (IABP) support. This case demonstrates the complementary diagnostic value of multimodality imaging-echocardiography for serial monitoring of the pericardial effusion and regional wall changes, and cardiac CT for direct characterization of the contained (sealed) defect-and the timely transition from conservative to surgical management in oozing-type rupture. The patient recovered uneventfully and was discharged in stable condition. Conclusions: This case highlights the diagnostic value of multimodality imaging-particularly cardiac CT-in detecting contained (sealed) LVFWR when echocardiography is inconclusive. Early recognition and prompt surgical intervention enabled a successful outcome in this otherwise frequently fatal complication.