Abstract 15948: Highly Suspicious Yet Diagnostically Unrevealing Left Ventricular Free-Wall Rupture Following STEMI

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Introduction: Left ventricular wall rupture is a rare but lethal complication following a ST elevation myocardial infarction (STEMI). We present a case of left ventricular free-wall rupture not identified on echocardiography and CT angiography (CTA) despite high suspicion who underwent emergent lifesaving mediastinal exploration and repair. Case: A 52-year-old male with past medical history of hypertension presented with typical chest pain. He was found to have STEMI with 100% left anterior descending (LAD) artery occlusion and underwent percutaneous coronary intervention to mid LAD. Post procedure, he developed atrial fibrillation with rapid ventricular rate, pericarditis, increasing pericardial effusion (Figure 1), and cardiogenic shock. He underwent intra-aortic balloon pump placement with no improvement in hemodynamics and subsequently an Impella 5.5 was placed. On post MI Day 3, he underwent pericardial window in the setting of shock and increasing pericardial effusion. Intraoperative TEE showed signs of tamponade physiology (Figure 2). Repeat echocardiograms and CTA was unrevealing of a rupture. Post MI day 6, he had increasing output from the drains and increasing pericardial effusion with complete right ventricular collapse on bedside echocardiogram. Emergent mediastinal exploration revealed left ventricular (LV) free-wall rupture which was repaired with a bovine patch. Hemodynamics improved and goal directed medical therapy was started. Discussion: Free wall rupture is a rare complication post MI and is reported in only 0.01% of STEMI. It usually occurs within 1 week, majority occurring within 24 h of MI. Small LV wall rupture can be challenging to diagnose on cardiac imaging. This case emphasizes the importance of having a high index of suspicion for diagnosing free wall rupture in patients presenting with hemodynamically unstable pericardial effusion post STEMI. Prompt pericardiocentesis and surgical intervention lead to a good outcome.

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