A Rare Case of Tamponade Without Myocardial Rupture Following a Subacute Infarction

TL;DR

This paper describes a rare and deadly case of heart-related shock caused by a subacute heart attack without visible heart muscle rupture.

Contribution

The paper presents a unique clinical case of hemorrhagic tamponade without myocardial rupture following a subacute infarction.

Findings

Hemorrhagic tamponade occurred without macroscopic myocardial rupture in a patient with no known medical history.

Emergency echocardiography was crucial for rapid diagnosis of pericardial effusion and cardiogenic shock.

The case highlights the severity of silent, progressing infarctions in undiagnosed atherosclerotic disease.

Abstract

Cardiac tamponade is a rare but serious complication of myocardial infarction, most often occurring in cases of complete myocardial rupture. Atypical forms, such as oozing-type rupture, without macroscopic rupture, can also cause a tamponade. We report an exceptional case of hemorrhagic tamponade due to subacute myocardial infarction without obvious myocardial rupture, occurring in a patient with no known medical history.

We report a case of a 70-year-old man who was found in shock on a public street after several weeks of atypical chest pain. On admission, he presented with cardiogenic shock and signs of peripheral hypoperfusion, severe hypotension, and tachycardia. Emergency echocardiography revealed a large circumferential pericardial effusion associated with global left ventricular hypokinesia. Biomarkers showed severe myocardial injury. CT angiography, performed before drainage to exclude aortic dissection requiring emergency surgery, confirmed the hemorrhagic effusion without dissection. While pericardial drainage was planned, the patient experienced refractory cardiac arrest. Salvage thoracotomy revealed a hemorrhagic effusion without macroscopic myocardial rupture. Post-infarction hemorrhagic tamponade may result from complete myocardial rupture (blowout) or from an “oozing” form, related to micro-tears or epicardial vascular fragility. In the present case, the rapid progression to terminal shock contrasts with previously reported cases in the literature, which were generally more subacute. Echocardiography provided an immediate diagnostic orientation, demonstrating its crucial role in managing shock. This case illustrates a rare but lethal complication of subacute myocardial infarction, i.e., hemorrhagic tamponade without complete myocardial rupture. It shows the importance of early tamponade diagnosis, the important contribution of emergency echocardiography, and the severity of silent-evolving infarctions in the context of unrecognized atherosclerotic disease.

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