Intramyocardial dissecting haematoma mimicking left ventricular clot, a rare complication of myocardial infarction: a case report

Abstract

Background Intramyocardial dissecting haematoma is a rare complication of myocardial infarction (MI) associated with high mortality rates. Studies and research of this occurrence are limited largely to isolated case reports or case series. Case summary We report a case of late presenting MI, where on initial echocardiogram had what was thought to be an intraventricular clot. However, upon further evaluation, the patient actually had an intramyocardial haematoma, with the supporting echocardiographic features to distinguish it from typical left ventricular (LV) clot. While this prevented the patient from receiving otherwise unnecessary anticoagulation, this diagnosis also put him at a much higher risk of mortality. Despite exhaustive medical and supportive management, death as consequence of pump failure occurred after 2 weeks. Discussion This report highlights the features seen on echocardiography which support the diagnosis of an intramyocardial haematoma rather than an LV clot, notably the various acoustic densities, a well visualized myocardial dissecting tear leading into a neocavity filled with blood, and an independent endocardial layer seen above the haematoma. Based on this report, we wish to highlight the importance of differentiating intramyocardial haematomas from intraventricular clots in patients with recent MI.

Case report: Recovery after large intramyocardial dissecting haematoma of the ventricular septum—a rare complication of myocardial infarction

“…Due to the scarcity of an intramyocardial haematoma, there are no exact estimates of incidence and prevalence, i.e., experience with this disease is limited to only a few cases. 1 , 8 Most commonly, it is described following MI or cardiac catheterization. 2 , 9 , 10 Intramyocardial haematoma after PCI oftentimes occurs after complicated retrograde percutaneous interventions of chronically occluded coronary arteries.…”

“… 11 TTE however remains the examination of choice to diagnose and monitor haemodynamically unstable patients with such condition. 1 …”

“…Intramyocardial haematoma is a rare complication of myocardial infarction (MI). 1 , 2 It is usually caused by a haemorrhagic dissection of the myocardium. 3 , 4 Hypothesized pathomechanisms are rupture of intramyocardial vessels into the interstitial area, reduced tensile strength of the infarcted area or an acute increase in coronary perfusion pressure.…”

Cardiovascular magnetic resonance and echocardiographic findings of a large thrombosed intramyocardial dissecting hematoma: a case report and a brief review of literature

“… 1 It occurs as a sequel of acute myocardial infarction due to therupture of the intramyocardial vessels or due to a sudden increase in the coronary perfusion pressure. 2 Pathologically, it is formed of intramyocardial blood with intact endocardial and epicardial integrity. 3 IMDH can involve the free or septal wall of the left ventricle (LV) or the right ventricle free wall.…”

Idiopathic left ventricular subendocardial dissecting hematoma

“…Other causes mentioned in the literature are injuries or complications of percutaneous interventions. Importantly, an IDH can be mistaken for a left ventricular lumen thrombus [4]. Consequently, the introduction of anticoagulant therapy may worsen the course of IDH with the threat of the rupture of the free wall of the heart muscle [5].…”