Sudden hemorrhagic tamponade simulating subacute ventricular rupture after acute myocardial infarction

Bloody tamponade is an unusual complication of pressure was 90/70 mmHg. Normal saline solution post-infarction pericarditis. The major cause of was given by vein with stabilization of the blood hemopericardium in this setting is left ventricular free pressure. The partial thromboplastin time was 136 s wall rupture. We report a case of post-infarction (therapeutic range 60–85) and the ECG was unhemorrhagic pericarditis mimicking subacute rupture changed. Twenty minutes later, while in the recumof the left ventricular free wall. bent position, the patient’s blood pressure fell to A 55-year-old man was admitted because of 2 h of 70/50 mmHg with a pulsus paradoxus of 15 mmHg. chest pain. Physical examination was unremarkable. There was jugular venous congestion, an S3 gallop An electrocardiogram (ECG) revealed 4-mm ST and no pericardial friction rub. Echocardiography segment elevation in the anterolateral leads. Aspirin, disclosed a moderate pericardial effusion with right alteplase, heparin and nitroglycerin were adminisatrial and right ventricular diastolic collapse and tered by vein with clinical signs of reperfusion. suspected intrapericardial thrombus over the anteroDuring the ensuing 10 days the patient had mild, lateral wall. Pericardiocentesis was attempted but intermittent, non-pleuritic chest pain. Repeated physonly 20 ml of blood (hematocrit: 29%) could be ical examination revealed an S3 gallop but no aspirated. A presumptive diagnosis of subacute ruppericardial friction rub. There were no ECG changes ture of the left ventricular free wall was made. At of either diffuse or localized pericarditis. Serial surgery 400 ml of blood were evacuated from the echocardiography, the last performed on the eighth pericardial cavity. The pericardium was severely and hospital day, demonstrated an enlarged left ventricle diffusely inflamed but there was no ventricular with antero-apical akinesis, severely reduced venrupture. The patient did well post-operatively and tricular function and no pericardial fluid. Captopril, was discharged after a short course of aspirin. furosemide and digoxin were added and intravenous The incidence of post-infarction pericarditis varies heparin was continued for suspected post-infarction between 14 and 25% [1]. Pericardial tamponade was angina. On the eleventh hospital day, the patient had not observed in these series [1], but was reported in a sudden episode of nausea and vomiting. Shortly 1% of patients treated with thrombolysis, evolving in thereafter he stood up to urinate and collapsed. Blood all cases during the first 24 h [2]. Our patient had only mild, non-pleuritic chest pain in the days *Corresponding author. Department of Cardiology, Hadassah Medical preceding the acute event, without clinical or laboraCenter, Ein Kerem, P.O. Box 12000, Jerusalem 91120, Israel. Tel.: 1972 2 6776563; fax: 1972 2 6437492. tory findings suggestive of pericarditis. At surgery,