Left atrial intramural hematoma: the main role of
echocardiography
Cosimo Angelo Greco MD1, Miriam Albanese
MD2, Ennio Carmine Pisanò MD3 ,
Massimiliano Garzya MD3, Mario Donateo
MD3, Salvatore Nicolardi MD1,
Antonio Scotto di Quacquaro MD1, Federica Mangia
MD1, Luigi De Razza MD1, Giovanni
Casali MD1, Salvatore Zaccaria MD1
1 Cardiac Surgery Department, Vito Fazzi Hospital, Piazza F. Muratore 1,
Lecce 73100, Italy.
2 School of Cardiology, ”A. Moro” University of Bari, Bari, Italy;
University Cardiology Unit, University Policlinic Hospital of Bari,
Bari, Italy
3 Cardiology and Intensive cardiac care Unit, Vito Fazzi Hospital,
Piazza F. Muratore 1, Lecce 73100, Italy
CORRESPONDING AUTHOR:
Name: Greco Cosimo Angelo
Address: Cardiac Surgery Department, Vito Fazzi Hospital, Piazza F.
Muratore 1, Lecce 73100, Italy.
e-mail address: cosimoangelo.greco@gmail.com
mobile phone: +39 3473656074
Fax number: none
ABSTRACT Left atrial intramural hematoma (LAIH) is an uncommon entity
for which a timely diagnosis is critical for decision making. Cardiac
surgical or catheter-based procedures are potential causing factors.
Though cardiac computerized tomography and magnetic resonance are highly
accurate diagnostic modalities, their role is limited by the lack of
widespread availability. The present clinical case illustrates the
diagnostic features of LAIH that can be obtained using echocardiography
at the bedside in critically ill patients. We report a case of LAIH,
that followed a catheter ablation procedure and was complicated by
cardiac and cerebral ischemia. Cardiac surgical management was required.
KEYWORDS intramural hematoma, left atrial dissection, radiofrequency
ablation, cardiac surgery.
Left atrial intramural hematoma (LAIH) has been defined as a disjunction
within the wall of the left atrium (LA) that creates a new chamber with
or without direct communication with the true LA cavity [1]. LAIH is
a rare complication related to any cardiac interventions, including both
surgical and catheter-based ones, involving manipulation of the LA
[2]. Recently, the number of cases of LAIH complicating
interventions of transvenous radiofrequency ablation (TRA) has been
increasing [3]. Spontaneous cases are also described [2,3]. The
disjunction within the wall forms a large cavity between the endocardium
and the epicardium of the LA, causing obliteration of the left atrial
cavity and resultant hemodynamic impairment, which in most cases
requires immediate surgical intervention. In contrast, LAIH without
hemodynamic instability can often be managed non-operatively with
satisfactory outcomes [2]. Although computerized tomography (CT) and
magnetic resonance (MR) have a crucial diagnostic role, they are not
widespread everywhere. Instead, echocardiography is a diagnostic tool
available in any setting, even at bedside in critically ill patient. We
present useful diagnostic features of LAIH obtained by echocardiography
as well long term follow up findings.
CLINICAL CASE: A 47-years-old man had recurrent attacks of atrial
tachycardia that did not resolve upon treatment with multiple
anti-arrhythmic drugs. His medical history was unremarkable except for
arterial hypertension. A TRA was scheduled. Three electrocatheters were
initially placed via right femoral vein into the right heart; a
non-fluoroscopic navigation system (CARTO3®; Biosense-Webster Inc.,
Irvine, CA, USA) was used for three-dimensional reconstruction of right
atrial anatomy and activation during atrial tachycardia; a single
trans-septal puncture (TSP) was performed under fluoroscopic guidance
and a SL1 sheath (St. Jude Medical Inc., Saint Paul, MN, USA) was
introduced into the LA, through which a 4-pole, 3.5 mm irrigation tip
ablation catheter (Navistar ThermoCool; Biosense Webster Inc., Irvine,
CA, USA) was also introduced. After three-dimensional reconstruction of
LA anatomy and activation during atrial tachycardia, TRA was carried out
with a Stockert RF generator with power limited to 35 W in the anterior
and 20 W in the posterior LA regions. A bolus of 8000 IU (100 mg/kg)
Heparin was given just after the TSP, and activated clotting time was
maintained at 250-350 seconds throughout the procedure. There was no
complication during the procedure. A few hours later, the patient showed
dysarthria and right arm hyposthenia. Brain-CT scan ruled out
hemorrhagic lesion, showing ischemic lesion in the territory of the left
middle cerebral artery. Transthoracic echocardiography (TTE)
demonstrated a very large LA mass adherent to posterior wall (fig.1) and
connected to interatrial septum by a pedunculated stalk (fig. 2),
causing a partial ventricular inflow tract obstruction. The mass seemed
to move in synchrony with left atrial wall (video 1), without
independent movement. In addition, it penetrated the atrio-ventricular
groove and it displaced anteriorly the posterior mitral leaflet (video
2). Furthermore, there was a thickening of the LA walls in areas far
from the mass, close to the aortic wall (fig. 3). All of these findings
suggested the diagnosis of LAIH. Furthermore, TTE showed posterior wall
motion abnormalities (video 3) and electrocardiogram showed a Q wave and
T wave inversion on inferior leads, so the patient underwent a coronary
angiography that revealed normal coronaries. Because of both the partial
ventricular inflow tract obstruction and the thromboembolic
complications (brain and myocardial ischemia), the patient underwent a
cardiosurgical procedure. Intraoperative transesophageal
echocardiography (TEE) demonstrated the huge dimension of the mass,
involving almost the entire LA (video 4) and confirmed the thickening of
the left atrial walls in areas far from the mass, close to the aortic
wall (fig.4). Surgical findings documented the presence of an intramural
atrial hematoma which was partially evacuated relieving the left
ventricular inflow obstruction. The patient’s neurologic deficits
resolved and he was discharged about 10 days after TRA. During the
follow up, there was a slow progressive reduction of the dimensions of
the lesion that, three years later, was almost completely reabsorbed
(video 5).
DISCUSSION: LAIH is a rare but potentially catastrophic complication
related to TRA [2], although it may occur after cardiac
interventions involving manipulation of the LA [2] and also
spontaneously [1]. The full spectrum of its pathogenesis, management
and definitive diagnostic criteria are not well established [4].
LAIH begins with an initial insult to the left atrial endocardium with
entry of pressurized blood to create a dissection within the left atrial
wall [2]. LAIH due to TRA may be caused by either a steam-pop effect
[5] or the creation of an endocardial flap of the left atrial wall
due to a stiff wire manipulation [2]. In our case it is likely that
the damage to the left atrial wall occurred during TSP, rather than
during the standard mapping or through ablation catheters. Regarding the
management, indication for surgery should be based on the clinical
presentation, including the degree of hemodynamic impairment and the
extent of the left atrial dissection [3]. In our case both the
partial ventricular inflow tract obstructions and the thromboembolic
events supported the surgical approach. Regarding the diagnostic
approach, wherever possible, multimodality investigation, using CT or
MR, is useful for an accurate diagnosis: MR enables a tissue
characterization [6-7], CT guarantees excellent spatial resolution
[8]. However, in an emergency setting, a multimodality diagnostic
approach with CT scan and MR is often not practical; instead,
echocardiography (transthoracic and/or transesophageal) allows to make
differential diagnosis with pericardial hematoma and mostly with LA
thrombosis requiring a different therapeutic approach. The following are
key elements for the diagnosis of the LAIH in echocardiography:
- Synchronous motion of an inhomogeneous mass with LA walls (video 1,2);
- Atrio-ventricular groove infiltration and anterior displacement of
posterior mitral leaflet in posterolateral LAIH (video 1,2);
- LA thickening in areas far from the mass (close to the aortic wall)
(fig. 3-4).
These features suggest that the lesion is within the LA wall and not
simply ‘leaning’ on it (as in the case of a thrombus or a myxoma) or on
its outer side (pericardial hematoma). The false peduncle (fig. 5)
represents the point in which the TSP induces hematoma formation. The
use of TEE for precise guidance of TSP may be a method to mitigate the
risk of this complication [9]. We did not perform TEE for
organizational issues. Faletra et al showed how the use of an imaging
guide may avoid complications related to inappropriate puncture sites.
When the catheter is against the fossa ovalis and the interventional
cardiologist applies pressure, the site of the puncture may be
identified by the “tenting” seen in two dimensional TE images. Since
TEE is usually performed before TRA in order to exclude left atrial
appendage thrombi, the interatrial septum could be evaluated to suggest
a TEE-guided TSP, especially in high-risk patients (i.e., those with a
previous transseptal crossing failure or severe kyphoscoliosis, septal
aneurysm, or aortic root dilation) [9].
CONCLUSION: LAIH is a rare complication of cardiosurgical and
transcatheter procedures. For the diagnosis, it is important both to
suspect it and to be aware of its imaging features. The
echocardiographic reported keys can help to make the differential
diagnosis and the optimal therapy. Intraprocedural TEE, during TRA, can
help to prevent intramural hematoma.
AUTHOR CONTRIBUTION:
Concept/design: CA Greco, M Albanese, S Zaccaria, G Casali, EC Pisanò
Data analysis/interpretation: CA Greco, M Albanese, S Zaccaria, G
Casali, EC Pisanò
Drafting article: CA Greco, M Albanese, S Zaccaria, G Casali, EC Pisanò
Critical revision of article: Cosimo Angelo Greco, Miriam Albanese,
Ennio Carmine Pisanò, Giovanni Casali, Massimilliano Garzya, Mario
Donateo, Salvatore Nicolardi, Federica Mangia, Antonio Scotto di
Quacquaro, Luigi De Razza, Salvatore Zaccaria
Approval of article: Cosimo Angelo Greco, Miriam Albanese, Ennio Carmine
Pisanò, Giovanni Casali, Massimilliano Garzya, Mario Donateo, Salvatore
Nicolardi, Federica Mangia, Antonio Scotto di Quacquaro, Luigi De Razza,
Salvatore Zaccaria
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Figure Legends:
- fig. 1: Parasternal long-axis view reveals irregular and disomogeneous
left atrium mass adherent to posterior wall. Ao: aorta. LAIH: left
atrial intramural hematoma. LV: left ventricle. RV: right ventricle.
- fig. 2: Parasternal short-axis view reveals left atrium mass connected
to interatrial septum by a pedunculated stalk. AoV: aortic valve.
LAIH: left atrial intramural hematoma. RA: right atrium. RV: right
ventricle.
- fig. 3: Parasternal long axis view reveals the thickening of the left
atrium in areas far from the mass (arrow ). Ao: aorta. LAIH:
left atrial intramural hematoma. LV: left ventricle. RV: right
ventricle.
- fig. 4: Midesophageal long axis view reveals the thickening of the
left atrium in areas far from the mass (arrow ). Ao: aorta.
LAIH: left atrial intramural hematoma. LVOT: left ventricle outflow
tract. RV: right ventricle.
- fig. 5: Parasternal short axis shows the false peduncle originating
from interatrial septum (arrow ). AoV: aortic valve. LAIH: left
atrial intramural hematoma. RA: right atrium. RV: right ventricle.
Embedded Video:
- Video 1: Parasternal long-axis view underlines synchronous motion of
the mass with left atrial walls.
- Video 2: Simultaneous multiplane transthoracic echocardiographic
images show atrio-ventricular groove infiltration and anterior
displacement of posterior mitral leaflet.
- Video 3: Parasternal short-axis view shows akinesia of the
infero-posterior wall.
- Video 4: Midesophageal long-axis view demonstrates the huge dimension
of the mass, involving almost the entire left atrium.
- Video 5: Simultaneous multiplane transthoracic echocardiographic
images prove the reduction of the dimensions of the lesion after three
years’ follow up.