Sealed Post-infarction Left Ventricular Free-Wall Rupture in a Patient Taking Dabigatran: A Case Report

Left ventricular free-wall rupture is a rare but life-threatening mechanical complication of acute myocardial infarction.In its subacute form, thrombus and pericardium temporarily contain the bleeding, opening a narrow window for diagnosis and surgery.We report a 76-year-old man with paroxysmal atrial fibrillation treated with dabigatran and with impaired renal function, who presented with syncope and cardiogenic shock after five days of untreated chest pain.The electrocardiogram (ECG) showed ST-segment elevation with QS complexes in leads I and aVL and reciprocal depression in the inferior leads, a pattern typical of first diagonal branch occlusion.Bedside echocardiography revealed a large, organized hemopericardium, and CT excluded aortic dissection.Coronary angiography confirmed occlusion of the first diagonal branch.Antithrombotic loading was withheld.At emergency surgery, a 1 × 1 cm tear of the mid-lateral free wall, matching the culprit territory, was found already sealed by thrombus; it was repaired with a sutureless patch technique combined with off-pump internal mammary artery grafting.After surgical re-exploration for recurrent postoperative bleeding, the patient recovered and was alive at 18 months.This case highlights the value of electrocardiographic localization, the central role of bedside echocardiography, and the practical issues raised by a direct oral anticoagulant at the time of rupture.