Contained Free Wall Rupture Following Thrombolysis in Acute Inferoposterolateral Myocardial Infarction: A Diagnostic Challenge

Abstract

Rupture of the free wall of the left ventricle occurs in approximately 1%–4% of patients with myocardial infarction (MI) and accounts for approximately 20% of total in-hospital mortality. Contained free wall rupture (CFWR) is a subacute variant in which the rupture is temporarily sealed by pericardial adhesions or thrombus, preventing immediate exsanguination. Here, we report the case of a 70-year-old female who presented with severe precordial chest pain radiating to the upper back with diaphoresis and near-syncope. Electrocardiogram with right-sided, left-sided, and posterior leads confirmed an extensive inferoposterolateral MI with right ventricular infarction. Echocardiography revealed severe left ventricular systolic dysfunction (ejection fraction of 26.1%) with regional wall motion abnormalities. Following thrombolysis with streptokinase, the patient developed cardiogenic shock, and repeat echocardiography revealed CFWR with mild pericardial effusion and echogenic material into the myocardium. Despite maximal supportive care, the patient succumbed on the third day. This case report underscores the diagnostic complexity of CFWR post-thrombolysis and the critical role of bedside echocardiography in timely recognition of this life-threatening complication.