67-year-old man presented to the emergency department 12 hours after the onset of chest discomfort. An electrocardiogram showed ST-segment elevation in the inferior leads (II, III, and aVF). The patient was immediately transferred to the cardiac catheterization laboratory, where he had a cardiac arrest with pulseless electrical activity. Emergency echocardiography revealed a large pericardial effusion; the effusion was drained by pericardiocentesis, which resulted in recovery of a spontaneous pulse, but the patient was hypotensive. In patients with a pericardial effusion after myocardial infarction, a mechanical complication such as rupture of the left ventricular free wall (a rare and catastrophic complication) is presumed. Since our institution does not have cardiac surgery available on site, the process of initiating transfer to the nearest cardiac-surgery center was begun immediately. However, before the patient could be transferred, coronary angiography showed three-vessel disease with subocclusion of the mid-right coronary artery. Left ventriculography confirmed a large left ventricular free-wall rupture with extravasation of blood and dye into the pericardial space .. During angiography, the patient’s condition became hemodynamically unstable, and pulseless electrical activity developed. Cardiopulmonary resuscitation was attempted but was unsuccessfu