No abstract

Introduction: Ventricular free wall rupture is an often fatal STEMI complication that has become increasingly rare thanks to early treatment of STEMI with primary percutaneous coronary intervention. Mortality is extremely high, with survival being dependent on early diagnosis and intervention as demonstrated in our case. Case: A 52 year old female with multi-vessel CAD and current tobacco use presented for acute, severe chest pain radiating to the jaw, throat, and upper back. She had been discharged the day prior after being medically managed for an inferior STEMI that had poor distal targets for CABG. Chest pain had been improving at time of discharge, but acutely worsened again the day of presentation and was accompanied by dyspnea. BP was persistently hypotensive despite aggressive fluid resuscitation. Physical exam was notable for diffuse tenderness of chest wall. Patient was alert and oriented. Troponin was down-trending from initial inferior infarct but still elevated. EKG still showed inferior infarct with no new changes. CTA chest, abdomen, and pelvis demonstrated hemopericardium and a linear focus of contrast enhancement involving the inferior left ventricular wall was seen on post-contrast images as shown in Figure 1. Patient was emergently taken to OR where intraoperative TEE with color doppler demonstrated color flow across the mid inferolateral wall consistent with myocardial perforation as seen in Figure 2. The hemopericardium was evacuated, a single-vessel coronary artery bypass-SVG to RPL was performed, and the myocardial rupture was closed with a pericardial patch. Patient survived and remained in the ICU for 10 days before being discharged.