Eur J Cardiothorac Surg 2002;21:119-120
© 2002 Elsevier Science NL
Epicardial haematoma: rare cause of acute myocardial ischaemia
M. Misfeld,
S.A. Khan,
C. Ilsley,
M. Amrani*
Department of Cardiothoracic Surgery, Harefield Hospital, Hill end Road, Harefield, Middlesex UB9 6JH, UK
Received 21 June 2001;
received in revised form 22 October 2001;
accepted 22 October 2001.
* Corresponding author. Tel.: +44-1895-828-550; fax: +44-1895-828-992
e-mail: m.amrani{at}rbh.nthames.nhs.uk
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Abstract
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Pericardial effusion and coronary dissection are well known complications of percutaneous transluminal coronary angioplasty (PTCA). We report a rare case of sub-epicardial haematoma after PTCA, leading to local compression and cardiogenic shock. We discuss the successful management of this problem.
Key Words: Subepicardial haematoma • Angioplasty • Myocardial ischaemia
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1. Introduction
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Percutaneous transluminal coronary angioplasty (PTCA) is a common cardiological intervention. Coronary dissection is speculated to be the most common complication after PTCA [1,2]. Major dissections are associated with a high rate of complications like acute coronary closure, myocardial infarction, emergency coronary artery bypass graft (CABG), cardiac tamponade, and death [1,3]. Treatment of complications is either conservative, interventional stenting or surgical [4]. Surgery entails either the drainage of pericardial effusion [3] or the treatment of myocardial ischaemia with CABG [5]. This report describes a rare case of myocardial ischaemia.
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2. Case report
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A 63-year-old female patient presented with a 2 year history of typical angina. Coronary angiogram showed occlusion of the circumflex coronary artery close to its origin. Left ventricular function was normal. PTCA of the circumflex artery was performed. AQ4 guide wire was passed via the right femoral artery followed by a Calypso balloon (AVE UK Limited, Harefield, UK) to dilate the artery. Finally a 2.5/18 mm AVE stent (AVE UK Limited, Harefield, UK) was deployed at 12 atmospheres pressure. It was a smooth uncomplicated procedure. Heparin infusion was commenced and the patient was transferred to the high dependency unit for routine monitoring. An early electrocardiogram after PTCA, showed no new changes. Activated partial thromboplastin time (APTT) was more than 65 s. Trans thoracic echocardiography (TTE) performed 2 h after PTCA showed one centimetre pericardial effusion with no signs of cardiac tamponade. Over the next 24 h, the size of effusion remained unchanged on repeated TTE by different investigators. Then the patient went into cardiogenic shock. She developed intermittent hypotension, drowsiness, oliguria and metabolic acidosis.(arterial pH was 7.19 with a base deficit of-14.1). ECG showed ST segment elevation in antero-lateral leads with no rise in cardiac enzymes. The patient was taken to the operating theatre. Intra-operative transoesophageal echocardiography (TOE) showed pericardial effusion, reduced lateral wall motion, and a well circumscribed bulge of the epicardium over the stented part of the circumflex artery, possibly due to subepicardial haematoma (Fig. 1). A median sternotomy was performed and about 400 ml of blood-stained pericardial fluid was evacuated. Signs of myocardial ischaemia still persisted at this stage. Within the area of the stented circumflex artery, between 1st diagonal and 1st obtuse marginal branches, a tense subepicardial haematoma, about 4 cm in diameter, was discovered. It was incised and evacuated to relieve the pressure on the coronary artery. Over the next few minutes, systolic blood pressure increased from 65 to 125 mmHg and central venous pressure dropped from 35 to 19 mmHg. The circumflex artery began to show good distal filling and TOE demonstrated improved lateral wall motion in the left ventricle. Adequate haemostasis was achieved in the area of the evacuated haematoma without additional suturing and the chest was closed. ECG changes normalized and cardiac enzymes remained unchanged. The patient was discharged on the seventh postoperative day. At follow-up clinic, 6 weeks later, she remained free of symptoms with a normal ECG.
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Fig. 1. Trans-oesophageal echocardiography (trans-gastric view, short axis) demonstrating subepicardial haematoma (<).
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3. Comments
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This case report describes a rare case of coronary ischaemia complicated by LV dysfunction and low cardiac output, which was totally relieved by drainage of sub-epicardial haematoma, without resorting to emergency CABG.
Plaque fracture in the stenosed coronary artery under high pressure balloon inflation helps in dilatation of coronary artery. Seepage of blood underneath the fractured plaque produces dissections.
Minor dissections after PTCA are common even in successful angioplasties [1,2]. In contrast, major dissections produce a high rate of complications [1,3] and of these, coronary artery perforation is reported to occur in 0.2–0.4% of cases leading to intra-pericardial haemorrhage with or without cardiac tamponade [3,4].
In this case, no extravasation of contrast medium was identified during PTCA. However, it has been reported that perforation can occur without angiographic evidence at the time of the procedure [4].
We do not know the exact mechanism, but we can speculate that intimal tear extended beyond the stent and it could not seal, but only reduce the leakage of blood. Rising pressure in the peri-adventitial haematoma gradually compressed the distal coronary artery producing myocardial ischaemia. Moreover, persistent seepage of blood produced slow development of pericardial effusion.
We initially treated the pericardial effusion conservatively, as it did not produce signs of tamponade. Eventually, a low cardiac output state forced us to drain it surgically. However, drainage failed to relieve ischaemia and low cardiac output till the sub-epicardial haematoma was relieved, indicating that haematoma was the primary cause of ischaemia.
Although the circumflex artery had initial chronic occlusion, its re-occlusion produced severe ischaemia with cardiogenic shock possibly through compression of the collaterals by the haematoma. Coronary angiogram was not done to confirm re-occlusion, as the patient rapidly became unstable.
Rehders and Nienaber [6] reported a similar case, where a subepicardial haematoma compressed left anterior descending artery (LAD) to produce myocardial ischaemia. Their case differs from our case as the haematoma occurred immediately after PTCA and emergency bypass graft to LAD was performed. We only drained the haematoma surgically. CABG was not considered to be necessary for three reasons: distal coronary branches filled normally, TOE confirmed improved regional wall motion and stent supported the dilated vessel well after drainage of haematoma and haemostasis.
In conclusion, we have described a rare complication after elective PTCA. Surgical drainage of sub-epicardial haematoma was enough to restore coronary blood flow. Therefore surgical reperfusion without grafting the coronary artery was possible in this rare instance.
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References
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Abstract
1. Introduction
