Abstract
We present a unique case of left atrial (LA) dissection in a 46-year-old man following aortic dissection surgery. The LA dissection was attributed to coronary sinus catheter–related injury. This report highlights the importance of recognizing this rare complication and the crucial role of transesophageal echocardiography in its diagnosis. We discuss the pathogenesis, diagnostic criteria, and management strategies for LA dissection.
Key Words: complication, coronary sinus, dissection, echocardiography, left atrium
Graphical abstract
History of Presentation
A 46-year-old man presented with sudden chest pain, dizziness, nausea, and vomiting and was given a diagnosis of Stanford acute type A aortic dissection. During the emergency operation, asystole was induced through antegrade infusion of a cold cardioplegia solution, and retrograde cardioplegia was administered through a coronary sinus (CS) catheter (BMR 2115, Beijing MEDOS AT Biotechnology Co, Ltd). The retrograde catheter was inserted smoothly into the CS through the right atrium. The ascending aorta and complete aortic arch were replaced using a 30-mm Gelweave (Terumo Aortic) graft, and a 28 × 100 mm stent was placed in the descending aorta. Following the restoration of cardiac activity, cardiopulmonary bypass (CPB) was terminated, and protamine was given to reverse heparin. Intraoperative transesophageal echocardiography (TEE) revealed a new, sizable mass along the posterior wall of the left atrium. The nonpulsatile mass had a circular shape with a well-defined border. Its echogenicity was heterogenous, featuring a combination of highly echogenic and echo-free areas, resembling honeycombing (Figures 1A to 1C, Videos 1 and 2).
Learning Objectives
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To understand the pathogenesis, diagnostic criteria, and management strategies for CSCRI-induced LA dissection.
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To emphasize the role of TEE in intraoperative monitoring of possible cardiac complications.
Figure 1.
Intraoperative Transesophageal Echocardiography Images
(A) Two-dimensional midesophageal long-axis (132°) view. (B) Two-dimensional midesophageal 5-chamber (0°) view. (C) Three-dimensional midesophageal bicaval view (92°); a well-circumscribed mass was observed in the left atrium (LA) (arrow). AO = aorta; LV = left ventricle; RA = right atrium; RV = right ventricle.
Past Medical History
This patient had no past medical history of chronic disease.
Differential Diagnosis
Differential diagnoses to consider for a left atrial (LA) mass include tumor, thrombus, vegetation, hematoma, and dissection. In our case, preoperative echocardiography in this patient displayed no abnormal structural echoes in the left atrium (Video 3), thereby excluding the possibility of tumor. In addition, the intraoperative TEE characteristics of this patient were inconsistent with vegetation and intramural thrombus. Considering a tendency for progression of the mass noted on TEE, LA dissection was a more likely diagnosis than hematoma.
Investigations
After monitoring for 2 hours, the mass showed progression on TEE that led to mitral valve compression and an elevated pulmonary artery pressure of 38 mm Hg; the patient’s right ventricular function was normal. Given the potential for further hemodynamically unstable progression, surgical exploration was conducted. A hematoma in the posterior LA wall was revealed (Figure 2), as the result of CS catheter–related injury (CSCRI) exacerbated by the retrograde cardioplegia infusion.
Figure 2.
Intraoperative View
A hematoma (arrow) was observed in the posterior left atrial wall.
Management
The surgical team successfully repaired the rupture by suturing along the CS without incising the left atrium for drainage. The effectiveness of the treatment was confirmed through intraoperative TEE.
Discussion
LA dissection can be caused by any cardiac intervention. The most common cause is mitral valve surgery, accounting for 52.8% of all factors in a retrospective study, yet there is no mention of CSCRI in that report.1 Retrograde cardioplegia through the CS has become an established method for providing myocardial protection. The incidence of LA dissection induced by to CSCRI is low (ranges from 0.053% to 0.093%),2 but it may be underestimated. In a literature search of the PubMed, only 5 reported cases of LA dissection related to CSCRI were found3, 4, 5, 6, 7 (Table 1).
Table 1.
Characteristics of 5 Reported Patients With Coronary Sinus Catheter-Induced Left Atrial Dissection
| First Author | Age, y | Sex | Diagnosis | Operation | Location | Treatment |
|---|---|---|---|---|---|---|
| Poirier et al3 | 72 | M | MR | MVR | Posterior wall | Conservative approach |
| Tsukui et al6 | 63 | M | MR, TR, and HOCM | MVR and TVP | Posterior wall | Hematoma opened from the inside of the left atrium for internal drainage |
| Kawago et al5 | 51 | M | Stanford type A AD | Partial arch replacement | Posterior wall | Conservative approach |
| Halline et al4 | 62 | F | Stanford type A AD | Hemiarch replacement | Posterior wall | Conservative approach |
| Fukuhara et al7 | 71 | M | Left main coronary artery dissection during PCI | CABG | Posterior wall | Drainage and repair |
AD = aortic dissection; CABG = coronary artery bypass grafting; HOCM = hypertrophic obstructive cardiomyopathy; MR = mitral regurgitation; MVR = mitral valve replacement; PCI = percutaneous coronary intervention; TR = tricuspid regurgitation; TVP = tricuspid valvuloplasty.
Factors contributing to this complication include catheter-related injury and pressurized inflow. The tear in the CS and the LA wall can occur during catheter insertion, and the pressure gradient between the CS and the left atrium can lead to LA dissection. Additionally, after separation from CPB, LA pressure remains lower than the pressure in the right atrium, and the pressure gradient can continue to pressurize the dissected cavity.6
TEE is a valuable diagnostic tool for LA dissection, which typically manifests as a hypoechoic space. In our case, the heterogeneous appearance of the mass could be attributed to blood clotting after coagulation correction with protamine sulfate.8 TEE can also identify communication between the false chamber and the CS, as well as obstruction of the pulmonary veins and mitral inflow, and it can assess hemodynamic stability in real time.
Management options for LA dissection include surgical intervention and conservative treatment,6 depending on the patient's hemodynamic status.9 In cases of acute LA dissection, the primary focal points should be evacuating blood from the false cavity and repairing the dissection entry point,7 but identifying the entry point is challenging. Conservative management is also an effective treatment option, especially for patients with stable hemodynamics. Previous reports documented successful outcomes with conservative management in 3 patients with LA dissection.3, 4, 5 Our case emphasizes the necessity of timely intervention for rapid LA dissection progression.
Follow-Up
Postoperative transthoracic echocardiography (TTE) demonstrated a 20% reduction in LA dissection size (Figure 3, Video 4), and pulmonary artery pressure and right ventricular function remained normal. The patient was discharged on postoperative day 18. Afterward, the patient underwent routine repeat TTE at the local hospital, with stable vital signs. The TTE conducted during the 4-month postoperative follow-up revealed no anomalies in the LA wall (Figure 4).
Figure 3.
Postoperative Transesophageal Echocardiography Images
Apical 4-chamber view on postoperative day 13. The red arrow points to the reduced left atrial dissection.
Figure 4.
Postoperative Transesophageal Echocardiography Images
Apical 4-chamber view captured during the 4-month postoperative follow-up.
Conclusions
Our report highlights a rare case of LA dissection resulting from CSCRI, thus accentuating the importance of recognizing this complication and using TEE for early diagnosis. Surgical intervention is effective in managing LA dissection, particularly in cases of rapid progression.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Intraoperative 2-Dimensional TEE, Midesophageal Long-Axis (120°) View With Color Flow Doppler
Intraoperative 3-Dimensional TEE, Midesophageal (92°) View
Preoperative TTE
Apical 4-chamber view without abnormal structural echoes in the left atrium.
Postoperative TTE
Apical 4-chamber view demonstrates the large hematoma in the left atrium.
References
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Associated Data
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Supplementary Materials
Intraoperative 2-Dimensional TEE, Midesophageal Long-Axis (120°) View With Color Flow Doppler
Intraoperative 3-Dimensional TEE, Midesophageal (92°) View
Preoperative TTE
Apical 4-chamber view without abnormal structural echoes in the left atrium.
Postoperative TTE
Apical 4-chamber view demonstrates the large hematoma in the left atrium.