Spontaneous closure of left ventricular free-wall rupture after acute myocardial infarction: a case report and review of the literature.

backgroundLeft ventricular free-wall rupture (LVFWR) is a rare but often fatal complication of acute myocardial infarction (AMI). While typically requiring emergency surgical intervention, spontaneous healing is exceptionally uncommon. This case is noteworthy for the spontaneous resolution of a left ventricular rupture in a hemodynamically stable patient, successfully managed with multimodality imaging and selective surgical revascularization. CASE PRESENTATION: A 66-year-old white European male with a history of hypertension and smoking presented with non-ST elevation myocardial infarction (NSTEMI) and was managed conservatively. Transthoracic echocardiography showed preserved left ventricular ejection fraction (55%) with lateral wall hypokinesia. The patient was discharged with a recommendation for coronary angiography. 1 month later, he was re-admitted for recurrent chest pain and dynamic electrocardiographic changes. Imaging revealed a rupture of the lateral left ventricular wall, confirmed by multidetector computed tomography (MDCT) and cardiac magnetic resonance (CMR), which showed a thrombus encased in fibrous tissue at the rupture site, along with minimal pericardial effusion. Despite the presence of a contained rupture, the patient remained hemodynamically stable. He underwent urgent coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA) to the left anterior descending artery. Intraoperatively, no rupture was evident apart from localized discoloration of the affected myocardium. The postoperative course was uneventful. 5 months later, follow-up CMR demonstrated regression of the thrombus and further fibrous remodeling, with restored myocardial integrity and an improved ejection fraction of 51%. Two years post-intervention, the patient remains asymptomatic with stable cardiac function.

conclusionsThis case illustrates that not all LVFWRs result in catastrophic outcomes. In selected patients with subacute, contained ruptures, spontaneous healing is possible under close surveillance and guided by advanced imaging. Cardiac CT and CMR were pivotal in characterizing the rupture, confirming myocardial stability, and informing treatment strategy. While surgery remains the standard of care, conservative management may be considered in hemodynamically stable patients, provided careful monitoring and multidisciplinary evaluation are ensured. This case underscores the critical role of multimodality imaging in assessing mechanical complications of AMI and supports the potential for individualized therapeutic approaches.