Background: Left ventricular wall rupture is a rare complication of myocardial infarction, occurring in approximately 2% of cases. Mortality is extremely high unless early diagnosis is made and urgent surgical intervention is provided. (1, 2)

Case report: 64-year old female patient with permanent atrial fibrillation and bioprosthetic aortic and mitral valve was admitted to Coronary Care Unit because of subacute myocardial infarction. She was on warfarin therapy due to secondary stroke prevention with an urgent INR of 2.7. Transthoracic echocardiography reveals hypokinesia of posterolateral wall, lobular pericardial effusion behind the posterolateral wall, and severe aortic stenosis and regurgitation of bioprosthetic valve. Urgent angiography showed occlusion of the obtuse marginal branch with spontaneous dissection of the distal segment without extravasation of contrast. Aortography showed severe aortic regurgitation without visible dissection. Because of high INR and pericardial effusion, we did not order a dual antiplatelet therapy. Control echocardiography exam verified pseudoaneurysm of ruptured posterolateral ventricular wall. Computerized tomography of the chest showed extravasation of contrast in the pericardium. For the purpose of surgical repair of left ventricular wall rupture and aortic valve replacement, patient was transferred to the Department of Cardiac surgery. During the hospitalization and transfer, patient was hemodynamically stable, without signs of tamponade. The patient died due to septic shock which occurred postoperatively.

Conclusion: We believe that rupture is result of combination of myocardial ischemia and pressure load caused by severe aortic regurgitation. Left ventricular wall rupture is often fatal complication and mortality is higher in the patients with other structural heart disease such as severe combined aortic disease.