A Rare Case of Fatal Left Ventricular Free Wall Rupture: Case Report and Short Review
Mahmoud Abdelnaby1*, Abdallah Almaghraby2, Yehia Saleh2, Muhammad Abdul Haleem3, Ashraf ElAmin2 and Basma Hammad4
1Cardiology and Angiology Unit, Department of Clinical and Experimental Internal Medicine, Medical Research Institute, University of Alexandria, Egypt
2Department of Cardiology, University of Alexandria, Egypt
3Department of Emergency Medicine, University of Alexandria, Egypt
4Massachusetts General Hospital, Boston, USA
- *Corresponding Author:
- Mahmoud Abdelnaby
Cardiology and Angiology
Department of Clinical and Experimental Internal Medicine
Research Institute, University of Alexandria, Egypt
Tel: +20 3 5921675
Received Date: July 05, 2017; Accepted Date: July 31, 2017; Published Date: August 07, 2017
Citation: Abdelnaby M, Almaghraby A, Saleh Y, Haleem MA, El Amin A, et al. (2017)
A Rare Case of Fatal Left Ventricular Free Wall Rupture: Case Report and Short
Review. J Cardiovasc Dis Diagn 5:290. doi: 10.4172/2329-9517.1000290
Copyright: © 2017 Abdelnaby M, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
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Left ventricular free wall rupture (LVFWR) is a rare, yet lethal, complication of acute myocardial infarction (AMI), occurring in approximately 2% of cases. In the era of percutaneous coronary intervention, however, it is less frequently encountered.
We were confronted with a case of AMI complicated with LVFWR after receiving thrombolytic therapy. The diagnosis was established using transthoracic echocardiography (TTE). Unfortunately, the patient passed away before surgical intervention. This case demonstrates the importance of prompt diagnosis and management of such a lethal complication.
Left Ventricular Free Wall Rupture (LVFWR); Myocardial
Infarction (MI); Thrombolysis; Percutaneous Coronary Intervention (PCI).
Left ventricular free wall rupture (LVFWR) is a rare complication
of acute myocardial infarction (AMI), occurring in approximately
2% of cases . However, due to progressive advances in the field of
percutaneous coronary interventions, LVFWR is becoming exceedingly
rare . Yet, still it is considered one of the most fatal complications of
AMI  (Figures 1 and 2).
Figure 1: TTE apical 4 chamber view showing a circumferential pericardial
Figure 2: TTE apical 4 chamber view showing apical LVFWR.
A 65-year-old male patient, current smoker, with no past medical or surgical history. presented to a primary health care hospital
complaining of severe typical chest pain that has been present for
6 hours. His electrocardiogram (ECG) showed extensive anterior
myocardial infarction. The patient received thrombolytic therapy
(streptokinase), however, the patient continued to have chest pain and
the ST segment elevation did not resolve. Consequently, the patient was
transferred to a tertiary care centre (Figures 3 and 4).
Figure 3: Non-contrast MSCT chest showing area of ventricular rupture.
Figure 4: Non-contrast MSCT chest showing area of massive pericardial effusion.
Upon arrival, the patient still had ongoing chest pain, he had stable
hemodynamic and follow-up ECG showed sinus tachycardia, lowvoltage
QRS complexes with diffuse ST segment elevation in anterior
chest leads and no electrical alternans. Bedside TTE revealed large nontamponading
pericardial effusion with suspected left ventricular (LV)
free wall rupture. Multi-slice Computed Tomography (MSCT) scan of
the heart with contrast revealed massive pericardial effusion and sealed
left ventricular free wall rupture with a hematoma (Figures 5 and 6).
Figure 5: Contrast MSCT chest showing sealed ventricular rupture with a
Figure 6: Contrast MSCT chest showing sealed ventricular rupture with a
massive pericardial effusion.
While the patient was being prepared for urgent surgery, he started to be lethargic and sweaty, he developed bilateral jugular venous
congestion and progressive hypotension. Cardiac auscultation revealed
no audible rub or gallop and no new murmurs, follow-up TTE revealed
tamponading pericardial effusion. Emergency peri cardiocentesis was
attempted while transferring the patient to the operating room but
unfortunately, the patient developed asystole and died.
LVFWR is a rare but devastating complication of AMI  diagnosis
depends on a high index of suspicion as well as close monitoring of
patient’s symptoms and signs [4-6]. TTE is considered the gold standard
for diagnosis of mechanical complications of AMI such as LVFWR .
MSCT may be a suitable alternative if the diagnosis is uncertain or
to exclude other causes of hemopericardium [8,9]. Cardiac magnetic
resonance (CMR) is mainly used for tissue characterization in patients
with subacute LVFWR or pseudoaneurysm who are clinically stable
Despite the high risk of operative mortality, urgent surgical repair
is still the definitive treatment. The usual approach is pericardial
patch closure of the defect or, less frequently, infarctectomy with
patch placement and ventricular wall reconstruction [12-14].
Pericardiocentesis should be done only as an emergency desperate measure if cardiac tamponade occurs while a surgical repair is planned
LVFWR is a catastrophic complication of AMI which is rarely seen
nowadays. Prompt diagnosis is mandatory, urgent surgical repair is
necessary to reduce its fatality.
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