Obstructive intramyocardial haematoma after percutaneous coronary intervention

Introduction

Nowadays, percutaneous coronary interventions are part of routine cardiology practice. However, serious complications may occur (4% in severe coronary disease [1]). In this case, a rare complication is described, where the use of on-site imaging and surgery is underlined.

Case

A 50-year-old man was referred to our centre to undergo an elective percutaneous coronary intervention (PCI). The patient was admitted to the referring hospital with atrial fibrillation and a rise of his cardiac biomarkers. Coronary angiography was performed showing a diffusely diseased right coronary artery (RCA) with an elongated stenosis in the mid segment of 70%. Furthermore a 60% stenosis in the circumflex (RCX) and a chronic occluded obtuse marginal (OM) branch were seen. His medical history included a prior posterior myocardial infarction 14 years ago treated by a PCI of his RCX. Medication on admission included acetylsalicylic acid, sotalol, losartan, fluvastatin and ezetimibe.

It was decided to perform a PCI of the RCA with placement of drug-eluting stents. After passage of a guidewire the lesion was directly stented with 3 Xience-V stents, dimensions 3.5 × 28 mm successively. After post-dilation until 30 atmosphere because of the massive calcification the angiographic result was satisfactory.

Two hours later the patient was referred back for re-catheterisation because he developed the clinical symptoms of inferior myocardial infarction. He experienced chest pain, paleness, intense perspiration, bradycardia and hypotension. Electrocardiography showed ST-segment elevation in the inferior leads (Fig. 1). Repeat coronary angiography was performed showing extravasation of contrast (Fig. 2). Cardiac ultrasound was carried out, showing a large intramyocardial mass in the right ventricular free wall, almost obliterating the right ventricular cavity (Fig. 3). Furthermore, a large amount of pericardial effusion, compressing the right side of the heart, was observed.

Fig. 1.

The ECG two hours after the first intervention

Fig 2.

Coronary angiography of the RCA showing extravasation of contrast medium

Fig. 3.

Echocardiography (apical four-chamber) showing pericardial effusion and a large intramyocardial mass

Pericardiocentesis was performed, with evacuation of 400 ml of blood. This did not improve his clinical status. Systolic blood pressure remained below 100 mmHg. The cardiothoracic surgeon was consulted who subsequently performed a surgical exploration through median sternotomy. A large amount of blood with thrombus was evacuated from the pericardium. Moreover, a large haematoma in the right ventricular free wall had ruptured in the pericardial space. The right ventricle was repaired with Teflon and Prolene, and sealed with Tacho-Seal and Tissue-col. The left internal mammary artery (LIMA) was distally anastomosed on the OM branch. Patient was successfully weaned from the heart-lung machine. Due to poor haemodynamic status and decreasing haemoglobin rethoracotomy was performed 12 h later, with pinching off the side branches of the LIMA and diathermic closure of several local arterioles.

The patient had an uncomplicated postoperative course, recovered well and could be discharged after 12 days. Two months later he was doing well, returning to his daily activities.

Discussion

This case emphasises the need for being aware of serious complications of percutaneous coronary interventions (PCI). Perforation of a coronary artery has become a rare complication (<1%) of PCI, even in the presence of extensive antithrombotic therapy [1]. In this case, the conventional risk factors of perforation, i.e. advanced age, female gender, tortuosity and use of stiff wires, were absent, with exception of high pressure postdilatation (30 atm).

Intramyocardial haematoma is a rare condition that has been reported in association with acute myocardial infarction [2], coronary angioplasty [3, 4], thrombolytic therapy [5] and chest trauma [6]. This complication of PCI is predominantly described in patients with prior coronary artery bypass grafting (CABG) [7]. It is presumed that adhesions between epicardium and pericardium obliterate the pericardial space, preventing the accumulation of blood from the perforated coronary artery in the pericardial space. So the flow is directed between epicardial and myocardial layers, causing an intramural mass, with complications such as cardiogenic shock or death [8]. To our knowledge, only a few cases demonstrating intramyocardial haematoma as a complication of PCI without prior cardiac surgery are described in literature [9].

The reason why, in our case, the flow chose its way between the myocardial layers, instead of only the pericardial layers remains unclear, because the course of the right coronary artery including the descending posterior artery is epicardial, not intramyocardial.

It is obvious that one single case can never direct standard therapy for a particular problem. But the favourable outcome of this patient supports the following recommendations. First, always perform an echocardiographic examination when patients are haemodynamically unstable after PCI. Secondly, when an intramural mass is found, direct consultation of a cardiothoracic surgeon is crucial. This is supported by the study by Pliam and Sternlieb [10], who found a mortality of 90% (mainly due to total myocardial rupture) in ten patients treated medically and 0% in 5 patients treated surgically.