Left ventricular free wall rupture is known to complicate acute myocardial infarction and is the second most common cause of inhospital mortality in this patient population. Contrary to widely held medical belief, this does not always result in immediate fatal pericardial tamponade with hemodynamic collapse. Up to 40% of such occurrences are subacute and may evolve over hours or even days. A high index of suspicion and accurate diagnostic tests are required to identify and treat these patients with emergent surgery. Echocardiography has emerged as an important diagnostic modality to identify this catastrophic condition. Although the literature has scattered reports on the role of transesophageal and transthoracic echocardiography in diagnosing free wall rupture, to date, only one report in the literature used ultrasound contrast agents to better delineate echocardiographic findings. We will present two cases in which echocardiography with use of intravenous ultrasound contrast agents was instrumental in helping to exclude rupture in one case and help identify rupture in another.

The number of centers that perform heart transplants has increased rapidly in recent years. Although transthoracic and transesophageal echocardiography (TTE and TEE) are utilized frequently to diagnose and manage cardiac complications commonly found in this population postoperatively, little has been written about the routine use of intraoperative TEE. Intraoperative echo is ideally suited to identify acute complications during cardiac transplantation. This can include immediate signs of rejection, valvular abnormalities, and mechanical complications related to the surgical procedure. Many of these patients might require ventricular assist devices (VAD) to provide circulatory support, and intraoperative TEE can be used to verify correct positioning of the VAD hardware. In addition, many of the chronic complications that patients with heart transplants are at risk for may be serious yet asymptomatic. Therefore, a high quality, complete intraoperative echocardiographic study might serve as an important baseline to compare postoperative changes.