Generally, the first step of treatment after diagnosis of LVFWR is pericardial drainage, IABP, intravenous transfusion and recovery to satisfactory hemodynamic status with inotropic support [
5], but there are cases where pericardial drainage re-ruptures due to the release of pressure on the lesion due to increased blood pressure or effusion [
6]. Accordingly, it has been reported that systolic blood pressure should not be higher than 80 mmHg [
7]. Additionally, once LVFWR develops, it is generally expected to present with shock, low cardiac output syndrome, and other dramatic conditions, and maintenance of circulatory dynamics is often important, so aggressive use of IABP or percutaneous cardiopulmonary support (PCPS) is recommended [
8‐
10]. IABP can be expected to reduce left ventricular afterload and left ventricular pressure through its systolic unloading effect, and our policy was to maintain IABP support for as long as possible [
11]. As CRP elevation is reported to be one of the characteristic findings of cardiac rupture [
12], the IABP placement was maintained until day 16 when this CRP turned negative while paying careful attention to the risk of thrombosis. It is generally accepted that LVFWR has a less favorable prognosis if treated without surgery [
9,
13]. However, if there is a blow-out type cardiac rupture, decompression by pericardial drainage may improve left ventricular contraction and cause a sudden increase in systolic blood pressure, which may enlarge the rupture site. Assuming that bleeding becomes uncontrollable and circulatory dynamics cannot be maintained, it is necessary to make close contact with cardiovascular surgery and switch to cardiac surgery such as sutureless repair (affixing a Tachosil: fibrinogen combined drug or pericardial patch to the rupture site), or suture. Meanwhile, considering that surgical mortality rates of 24–35% have been reported, there is no clear evidence that it should be performed in all patients [
14‐
16]. Mathew et al. stated that some cases could be treated without surgical intervention if a large-scale study was conducted [
17]. It is not rare to avoid surgical intervention for various reasons, and even if a surgical operation can be done, cases of early re-rupture after surgery have also been reported [
18]. Therefore, it is very important to provide medical intervention even after surgery. In this case as well,the long-term bedrest and the administration of beta-blockers may have been important factors in preventing recurrence [
19,
20]. At a heart team conference that included cardiovascular surgeons, it was determined that the patient was elderly and that surgical manipulation of the fragile myocardial tissue would result in high risk of hemostasis difficulties and transition to a blow-out type of bleeding. Therefore, we decided to delay or avoid open chest surgery to the extent possible. In the case of bleeding associated with an anterior wall infarction, it is difficult to stop bleeding due to hematoma compression. In our case of such posterior wall lesions, it is thought that the weight of the heart also contributed to hemostasis [
21]. Figueras et al. have said that surgical intervention should be considered for patients that have difficulty in controlling arterial hypertension, and patients who have a recurrence of tamponade after pericardial drainage. However, “medical management might be of particular value in patients with a lateral or an inferoposterior AMI or those at very high surgical risk, such as those with a large infarct area or those > 75 years old [
22].” Such patients should remain at or be transferred to an institution with surgical backup, considering the risk of re-rupture or metachronous double-rupture [
23]. Moreover, even if a patient emerges out of an acute phase, there have been reports of ventricular aneurysms occurring in the chronic phase, and thus attention needs to continue thru this period [
24].
We experienced a case of an elderly woman who was diagnosed with an acute exacerbation oozing-type (blow-out migration of oozing-type) left ventricular free wall rupture due to AMI. She had temporary aggravation, but subsequently was discharged from the hospital with only conservative treatment. As there are few reports on conservative treatment of left ventricular free wall rupture, we report our case as an example.