Contained ventricular free wall rupture without pericardial effusion: a diagnostic challenge in acute myocardial infarction

Left ventricular free wall rupture is a rare but often fatal complication of acute myocardial infarction (MI). While typically associated with pericardial effusion and tamponade, left ventricular free wall rupture can occasionally present as a contained rupture, leading to diagnostic delays. A 69-year-old woman with prior mitral and tricuspid valve repair and atrial flutter treated with apixaban presented with cardiogenic shock following a posterior ST-elevation MI. Coronary angiography revealed thrombus in the right coronary artery and thrombotic occlusion of the left circumflex artery (LCx)- obtuse marginal (OM) branch. During evaluation for mechanical support, echocardiography suggested a large left ventricular mass. Further imaging raised suspicion of an intramural hematoma without pericardial effusion. Surgical exploration confirmed a sealed ventricular rupture contained by the parietal pericardium. Despite timely intervention, the patient succumbed to her condition. This case emphasizes the diagnostic challenge posed by left ventricular free wall rupture without pericardial effusion. High clinical suspicion, even in atypical presentations, and rapid multidisciplinary management are critical for improved outcomes. • This case highlights an atypical presentation of ventricular free wall rupture—without pericardial effusion—posing a diagnostic dilemma that can lead to delayed recognition and intervention. The contained rupture mimicked an intramural mass, complicating immediate surgical decision-making. The key takeaways include: • High clinical suspicion: a sudden, unexplained cardiogenic shock post-myocardial infarction should prompt consideration of ventricular free wall rupture, even in the absence of pericardial effusion. • Imaging pitfalls: traditional reliance on pericardial effusion as a diagnostic hallmark may delay appropriate intervention in sealed ruptures. • Emergent surgical approach: early intervention remains crucial despite diagnostic uncertainty, as a contained rupture can rapidly progress to catastrophic decompensation. • This case underscores the necessity for heightened vigilance and rapid multidisciplinary coordination in managing rare but fatal MI complications.