Fatal Huge Left Free Wall Ventricular Rupture after Acute Posterior Myocardial Infarction

A 77-year-old man, with a recent history of an acute inferior myocardial infarction, was referred to our hospital with echocardiographic and clinical signs of left ventricular free wall rupture (LVFWR). The intraoperative finding demonstrated a huge double LVFWR. The inferoposterior wall was dramatically destroyed without any possibility to repair. Cardiac rupture represents a catastrophic complication of myocardial infarction with an incidence of 6% in the prereperfusion era [1]. In the reperfusion era, its incidence is between 1% and 3% of all myocardial infarction patients [2]. Despite significant improvement in the diagnosis and therapy of myocardial infarction, in-hospital death in patients complicated by cardiac rupture remains dramatically high. We describe the case of 77-year-old man who was admitted to peripheral hospital with chest pain and mild ST elevation on D2, D3, and aVF leads at the time of electrocardiogram admission. Diagnosis of acute posterior-inferior myocardial infarction was made, and the patient underwent prompt cardiac catheterization, which showed a proximally total occlusion of the right coronary artery. Due to initial symptoms of low cardiac output, a transthoracic echocardiogram was performed and pericardial effusion was detected. Therefore, the patient was referred to our hospital with echocardiographic and clinical signs of pericardial tamponade with the suspicion of left ventricular free wall rupture (LVFWR) to undergo emergently surgical repair. The patient arrived to our unit about 2 hours after initial symptoms. On arrival to operating room, the patient showed clinical signs of low cardiac output despite conventional therapy with inotropes and vasoconstrictor; the blood pressure was 80/50？mmHg, the pulse rate was 65 beats/min, the extremities were cold, and the urine output was less than 0.5？mL/Kg/min. The patient was promptly intubated and ventilated. A standard longitudinal sternotomy was performed, and the pericardium was opened. A fresh clot was observed over the inferior left ventricular wall. The systolic pressure dramatically raised, but suddenly a huge bleeding was observed into the pericardial cavity, and a pulseless ventricular tachycardia occurred. A sinus rhythm was obtained after internal DC shock at 7？Joule, cardiopulmonary bypass was established immediately, and the heart was arrested. The intraoperative finding showed a huge double LVFWR. One rupture was located in the territory of posterior descending artery for a length of about 6？cm (Figure 1, * mark), while the other rupture was located along the