Contained ventricular free wall rupture without pericardial effusion: a diagnostic challenge in acute myocardial infarction

Background

Left ventricular free wall rupture is a rare but often fatal complication of acute myocardial infarction (MI). While typically associated with pericardial effusion and tamponade, left ventricular free wall rupture can occasionally present as a contained rupture, leading to diagnostic delays.

Case summary

A 69-year-old woman with prior mitral and tricuspid valve repair and atrial flutter treated with apixaban presented with cardiogenic shock following a posterior ST-elevation MI. Coronary angiography revealed thrombus in the right coronary artery and thrombotic occlusion of the left circumflex artery (LCx)- obtuse marginal (OM) branch. During evaluation for mechanical support, echocardiography suggested a large left ventricular mass. Further imaging raised suspicion of an intramural hematoma without pericardial effusion. Surgical exploration confirmed a sealed ventricular rupture contained by the parietal pericardium. Despite timely intervention, the patient succumbed to her condition.

Discussion

This case emphasizes the diagnostic challenge posed by left ventricular free wall rupture without pericardial effusion. High clinical suspicion, even in atypical presentations, and rapid multidisciplinary management are critical for improved outcomes.