Large Epicardial Hematoma After Percutaneous Coronary Intervention: Multimodality Imaging

J INVASIVE CARDIOL 2019;31(3):E49-E50.

Key words: cardiac imaging, computed tomography, transesophageal echocardiogram, transthoracic echocardiogram

An 87-year-old man with a history of coronary artery bypass grafting (CABG) underwent cardiac catheterization for unstable angina. He was found to have an occluded vein graft to a marginal artery with severe 80% stenosis of the proximal left circumflex artery (white arrow, Figure 1A; Video 1), which was successfully intervened upon with a 3.25 x 12 mm Xience Alpine drug-eluting stent (Abbott Vascular) (white arrow, Figure 1B; Video 2) utilizing weight-based heparin for anticoagulation.

Thirty minutes after the procedure, the patient complained of chest discomfort and dyspnea with associated tachycardia and hypotension. Electrocardiogram did not show any ischemic ST-segment changes. Emergent transthoracic echocardiography showed a large compressive mass (crossed arrows, Figures 1C and 1D; Videos 3 and 4) adjacent to the right ventricle (RV) causing near obliteration of the RV cavity (black arrow, Figure 1D). Left ventricular function was normal. Computed tomography (CT) of the chest showed a large, 7.1 x 7.2 cm epicardial hematoma (white arrows, Figure 1E) resulting in severe mass effect upon the RV. Delayed enhancement of the hematoma did not suggest any active extravasation. Due to hemodynamic compromise, the patient was taken to the operating room for epicardial hematoma evacuation. A large amount of thrombus was removed (Figure 1F). Pre- and postevacuation intraoperative transesophageal echocardiography showed significant reduction in the hematoma and improvement of RV function (Figures 1G and 1H; Videos 5 and 6).

Epicardial hematoma can manifest immediately or within a few minutes to hours after coronary intervention. Review of the angiogram after the diagnosis of hematoma, in our case, showed deep distal positioning of a non-polymer jacketed wire (Figures 1I and 1J; Video 7) – the most likely cause of the adverse outcome. Multimodality imaging is critical for diagnosis and management of such cases.

See the Supplemental Videos here.

From Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 25, 2018.

Address for correspondence: M. Fuad Jan, MBBS, MD, Aurora Cardiovascular Services, Aurora St. Luke’s Medical Center, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI 53215. Email: publishing18@aurora.org