Long-term survival of post-infarction free wall rupture without operation.

fractions and congestive heart failure. Il-forming pathways in normal and failing human hearts Circ Res 1990; 66: 883-90. [3] Urata H, Boehm KD, Philip A et al. Cellular localization and regional distribution of an angiotensin Il-forming chymase in the heart. el al. Progression of left ventricular dysfunction during enalapril therapy: relationship with neuro-hormonal reac-tivation. Myocardial free wall rupture is the second most frequent cause of in-hospital mortality in acute myocardial infarction 1 ' 1. Sudden rupture leads to instantaneous death. Long-term survival has been reported in less than 100 cases of subacute ventricular rupture treated surgically with repair of the tear 121. If the rupture is gradual, the space into which the rupture opens can be confined by the epicardium and pericardial adhesions. This outcome has been described as pseudoaneur-ysm [31 which is prone to spontaneous rupture and therefore requires surgery as soon as diagnosed' 41. Echocardiog-raphy is the technique of choice to recognize free wall rupture early and accurately 131. Pericardiocentesis can relieve tamponade in patients with free flowing pericardial effusion while they await surgery. We present a patient in whom echocardiographically guided pericar-diocentesis led to long-term survival without either subsequent surgical repair or pseudoaneurysm formation. Such a case, to our knowledge, has not been reported in the literature. A 76-year-old man was admitted to our hospital within 15min of syncope without previous cardiac symptoms. The patient presented in shock with distended neck veins and no signs of pulmonary congestion. The electrocardiogram demonstrated ST segment elevation and Q waves in inferior leads. The elevation of CPK, CPK-MB and alpha HBDH enzymes proved the diagnosis of acute myo-cardial infarction of more than 24 h Figure 1 Subcostal two-chamber view showing pericardial effusion (PE) and an echo-dense intrapericardial mass suggesting thrombus (arrows). LV=left ventricle; RV = right ventricle. duration. Because of the shock and the signs of tamponade, echocardiography was promptly performed. It showed inferior wall akinesia and pericardal effusion which was 24 mm in diastole on the diaphragmatic surface of the right ventricle. In the pericardial space there was an echo-dense mass consistent with clot. The right ventricle and the left atrium were compressed and the inferior vena cava was dilated (Fig. 1). Echo guided pericardiocentesis with Seldinger's technique produced 250 ml arterial blood (haematocrit 25%, pO 2 90mmHg) and sudden improvement of the patient's haemo-dynamic and mental state. As the staff were busy with other patients, emergency surgical intervention …