Acute Left Ventricular Free Wall Rupture During Echocardiography

An 81-year-old man with known hypertension, new diagnosis of diabetes, and no history of smoking or coronary heart disease was referred to our emergency department because of malaise and dizziness. The electrocardiogram (ECG) showed Q waves in I, II, III, aVF, V5, and V6 consistent with prior inferolateral myocardial infarction (MI). Troponin T (3.14 g/L; normal value 0.10 g/L) and creatine kinase (788 U/L; normal value 50-200 U/L) were elevated. Based on these findings, subacute MI was the most likely diagnosis. Four days later, the patient underwent echocardiography that showed an ejection fraction of 40% to 45% with an inferolateral and anterolateral hypokinesia (Figure 1; Videos 1 and 2). Otherwise the echocardiography finding was normal. During the examination, the patient lost consciousness, carotid pulse was not palpable, and the patient had congested jugular veins. The ECG demonstrated signs of a new inferior and anterolateral S-T elevation MI and rapidly progressed to a pulseless electrical activity. A cardiac rupture with tamponade was suspected and confirmed by echocardiography, which revealed a large pericardial effusion and thrombus formation (Figure 2; Video 3). Despite cardiopulmonary resuscitation and attempt of pericardial drainage, the patient died on the echocardiog-