A Rare Complication of Primary Percutaneous Coronary Intervention: Left Atrial Dissection and Hematoma
Introduction: Left atrial dissection and hematoma are a life threatening condition, which are rarely seen following percutaneous coronary interventions. Diagnosis of these complications may sometimes be difficult, despite the use of the latest imaging techniques. The case presented in this paper is the first case of left atrial dissection and hematoma as complications following primary percutaneous coronary intervention.
Case Presentation: A 65-year-old male patient was admitted to the emergency department and acute inferolateral myocardial infarction was diagnosed. The left atrial hematoma as a rarely complication is developed in patients undergoing primary percutaneous coronary intervention.
Conclusions: Preoperative echocardiography, applied before elective and emergency percutaneous coronary interventions, plays a key role in detecting many intervention-related complications in the post-intervention period.
Keywords: Complication; Primary PCI; Hematoma; Acute Coronary Syndrome
Coronary artery perforation is seen as a complication in 0.1% - 0.3% of patients, following percutaneous coronary intervention (PCI). The rate of perforation incidence is about 0.1% during balloon angioplasty or stent procedures, and use of ablation devices, such as a rotablator, excimer laser, atherectomy and transluminal extraction catheter, increase its incidence (0.3%) (1). In recent years, the use of PCI ablation devices have shown a decreasing trend. Instead of this, interventions for more complicated lesions containing calcification, severe angulation and chronic total occlusion have been more common. Rigid and hydrophilic wires have been used to treat these complicated lesions and balloon dilatation requires high pressure. In addition, the growing use of glycoprotein IIb/IIIa inhibitors has increased the occurrence of coronary artery perforation (2).
2. Case Presentation
A 65-year-old male patient was admitted to the emergency department of a health center with a one-hour history of chest pain. Acute inferolateral myocardial infarction was diagnosed. The patient was sent to the catheter laboratory for primary PCI. Coronary angiography revealed a normal left main coronary artery (LMCA), 70% - 80% stenosis in the left descending artery (LAD) at the level of diagonal 1, a totally blocked middle segment of the circumflex artery (CX) and 50% stenosis in the mid-portion of the right coronary artery (RCA). First soft, then hydrophilic and rigid wires were used, which failed to open the completely blocked segment in the circumflex artery, and the procedure was terminated as an unsuccessful primary percutaneous coronary intervention (Figure 1). Following the intervention, the patient complained of increase in dyspnea, and echocardiography was performed that revealed a left atrial mass. The patient was referred to our clinic for mass excision and coronary bypass graft operation with the suspicion of myxoma. After admission to our center, transthoracic (TTE) and transesophageal echocardiography (TEE) were performed, which revealed a left atrial dissection, hematoma and pulsatile active arterial flow in the dissection band detected by Doppler (Figure 2). The patient, who had an unstable hemodynamic status, was operated on for coronary artery bypass grafting, hemorrhage control and hematoma excision. Following distal anastomosis of the LAD-saphenous vein, a left atriotomy was performed showing that a mass was filling up almost the whole atrium, and a hematoma originating from the left atrial dissection was blocking blood flow through the mitral valve (Figure 2). Since TEE demonstrated an arterial fistula causing jet flow in the left atrium (Figure 2), pressure was applied on the CX artery above the atrio-ventricular groove, which blocked the flow. The CX artery in this region was ligated with sutures and the flow towards the left atrial dissection was stopped. The operation was terminated with inotropic support, following the normalization of temperature and pressure values.
A, Coronary angiography reveals 50% stenosis in the mid-portion of right coronary artery; B and D, 70% - 80% stenosis in the left anterior descending artery at the junction point with diagonal 1; C, Normal main coronary artery and totally blocked middle segment of circumflex artery.
A and B, Transthoracic and transesophageal echocardiographic images; C, The image similar to myxoma originating from fossa ovalis in the left atrium was revealed to be a left atrial dissection and thrombus, intra-operative image of left atrial thrombus.
Penetration of the left atrium, hemorrhage secondary to dissection and hematoma formation are rarely seen complications following percutaneous coronary interventions. The best known causative factors are spontaneous complications (3), mitral valve surgery (4), electrophysiological study (5), myocardial infarction (6) and blunt thoracic trauma (7). A literature search revealed no left atrial dissection and hematoma reports following primary percutaneous coronary intervention, and only a few cases secondary to elective percutaneous coronary intervention were present (8). We believe that in this case, myocardial infarction occurred due to a thrombus originating from rigid plaque, and dissection and bleeding into the left atrium took place while placing the guide wire into distal vasculature during the intervention. This penetration was undetected, and the left atrial mass seen on echocardiographic examination was considered a cardiac tumor originating from the foramen ovale. A coronary bypass graft operation and tumor excision was scheduled. After the patient complained of increased dyspnea and his general status had started to deteriorate, the possibility of hematoma was considered. Left atrial dissection and hematoma is a life threatening condition, which needs to be urgently diagnosed and treated. Diagnosis may sometimes be difficult despite the use of the the latest imaging techniques. Preoperative echocardiography, applied before elective and emergency percutaneous coronary interventions, plays a key role in detecting many intervention-related complications in the post-intervention period. In this case, the type of intervention, information of possible complications that may occur following the intervention and the presence of preoperative cardiac imaging examination results all assist us in urgent diagnosis and treatment of possible complications (tamponade, intracardiac hematoma etc.).
Since the present case was eligible for coronary artery bypass grafting, the patient’s general condition was poor and ischemia persisted, the best treatment method to be applied was surgical coronary artery bypass grafting with urgent left atriotomy to control hemorrhaging and remove the thrombus (9).
The presented case is the first case of a patient with left atrial dissection and hematoma as complications following primary percutaneous coronary intervention. This case emphasizes the value and lifesaving features of preoperative, as well as postoperative, evaluation for many life-threatening complications. In such cases, difficulties in diagnosis may cause loss of time, prolongation of the treatment period and difficulties in treatment. Urgent diagnosis and appropriate treatment will be lifesaving.
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