Conservative Treatment of a Left Atrial Hematoma and a Localized Tamponade Occurring During Treatment of Coronary Total Occlusion

Abstract

C ardiac tamponade during percutaneous coronary intervention is a rare but serious complication that can occur after coronary perforation. Even more infrequent is a tamponade subsequent to a localized left atrial hematoma. In the literature, we found just 5 similar cases, and all of them underwent surgical intervention. [1][2][3][4] The surgical option, using a median sternotomy or left thoracotomy approach, was taken in the first hours after the procedure because of progressive hemodynamic deterioration. In 4 of them, it consisted of hematoma drainage and atrial decompression; in 1 patient, the surgical option was vessel wall repair. We report our experience of a patient who sustained this complication as a consequence of a large right coronary dissection. The patient was treated conservatively with a successful outcome.A 65-year-old man, previously treated with coronary artery bypass graft surgery and coronary percutaneous revascularization, was still symptomatic with effort angina refractory to maximal medical treatment. Myocardial scintigraphy showed evidence of inducible ischemia in the inferolateral left ventricular wall. He was hospitalized in our institution to attempt to recanalize the chronic occlusion of the right coronary artery (RCA). During the procedure, a subintimal dissection occurred in the middistal segment of the right coronary artery ( Figure 1A and 1B), and in the more distal part of the posterolateral vessel, it resulted in a perforation of an atrial branch. Perivascular dye staining and contained extravasation were observed, although no pericardial opacification was noticed at fluoroscopy. After a few minutes, hemodynamic instability occurred, requiring dopamine support. The transthoracic echocardiogram showed a voluminous left atrial mass that almost obliterated the left atrial chamber. No pericardial effusion was present (Figure 2A and 2B). Protamine was administered to neutralize the heparin given during the procedure. Aspirin and clopidogrel were stopped.The patient was transferred to coronary care unit for monitoring and treatment. Hemodynamic instability (pulmonary congestion and hypotension) was treated with dopamine (10 ␥ · kg Ϫ1 · min Ϫ1 ) and high-dose diuretic infusion. Cycles of facemask continuous positive airway pressure ventilation were used. A transesophageal echocardiogram showed a hypoechogenic, inhomogeneous, vacuolated large spheric mass (55ϫ60 mm in dimension) occupying a large portion of the left atrium. Flow obstruction was detected with color Doppler examination of mitral inflow ( Figure 3A through 3C). A magnetic resonance examination clearly characterized the hemorrhagic nature of the mass (Movie I in the online Data Supplement and Figure 4). A new angiographic evaluation the day after the procedure excluded an ongoing blood supply to the hematoma, and the RCA was occluded proximally.Therapeutic options were discussed with the intensive care physicians and cardiac surgeons. We decided on conservative management. Dopamine was definitively withdrawn on the eighth ...

Left atrial inflow and outflow obstruction as a complication of retrograde approach for chronic total occlusion

“…Although this case is unique in relation to the retrograde approach and epicardial collateral perforation, there have been eight previous English language case reports of LA inflow obstruction either from compression or mass obstruction from the antegrade PCI approach (Table I) [4][5][6][7][8][9][10][11]. At least three of the cases were considered intra-myocardial hematomas based on echocardiographic findings [9][10][11].…”

Conservative treatment of a left atrial intramural hematoma after left atrial thrombus resection and concomitant mitral valve replacement - case report

“…Intramural left atrial hematomas are a very uncommon entity, but have been described to occur spontaneously [1-4], after aortocoronary bypass surgery [5], after percutaneous coronary interventions [6,7], radiofrequency catheter ablations [8,9] and after blunt chest trauma [10]. …”

Left atrial dissection

“…Three patients had both mitral and aortic valve surgery [1,12,14]. Of 16 patients with CAD, 7 patients (43.8 %) had PCI [38][39][40][41][42][43], 5 (31.3 %) had CABG [2,[44][45][46][47], and 4 had no procedure [1,[48][49][50]. PCI was performed to the left circumflex artery in 4 patients and to …”