LAUSR

A 73-year-old man suddenly fainted and was brought to our hospital. In the ambulance, the patient exhibited pulseless electrical activity requiring immediate cardiopulmonary resuscitation. After return of spontaneous circulation in the emergency department, electrocardiography showed ST-segment elevation and Q waves in leads II, III, and aVF (Fig. 1a). Initial transthoracic echocardiography revealed normal wall motion and thickness, a small amount of pericardial effusion, and left pleural effusion. Despite no signs of obstructive or cardiogenic shock, hypotension requiring hemodynamic support persisted. Contrast-enhanced computed tomography showed leakage of contrast medium from the left ventricle into the pericardium and hemorrhagic fluids in the mediastinal and left thoracic cavity (Fig. 1b–d). Repeated transthoracic echocardiography showed increased left pleural effusion without increasing pericardial effusion. These findings suggested rupture of both the left ventricular free wall and the pericardium. Percutaneous veno-arterial extracorporeal membrane oxygenation was not successful in supporting his hemodynamics and open-heart surgery was not indicated by surgeons due to massive bleeding. The patient died after a few hours. We should be aware that combined rupture of the left ventricular free wall and pericardium may present as hemothorax without severe signs of cardiac tamponade, which could cause a delay in diagnosing cardiac rupture.