Case Presentation:
A 77-year-old man with known obstructive coronary artery disease
presented to the cath lab for coronary intervention of his left
circumflex artery. This was a trifurcation lesion involving the
2nd and 3rd obtuse marginal branch
as well as the ongoing AV groove circumflex. Due to significant vessel
overlap the guide wires had to be repositioned multiple times, wires
were placed in the OM branch and the ongoing Left circumflex. During the
procedure one of the wires was inadvertently advanced into the AV
circumflex branch. Initial balloon angioplasty was then done with a 2.0
balloon (Euphora, Medtronic) ) A 2.75 x 15 mm stent (Resolute Onyx,
Medtronic) was deployed in the obtuse marginal branch and 3.0 x 23 mm
stent(Resolute Onyx, Medtronic) was delivered in the proximal left
circumflex. Kissing balloon inflations in the two obtuse marginal
branches were performed. Following that, the proximal circumflex was
dilated with a 3.0 noncompliant balloon. Final angiographic results were
good. Review of the films post procedure suggested that there may have
been faint contrast staining from wire in the left atrial circumflex
branch.
About an hour following the procedure the patient developed chest
discomfort and became hypotensive with a blood pressure of 78/57 mmHg.
He was successfully resuscitated with iv fluids. Repeat EKG did not show
any significant changes. An urgent echocardiogram was performed. The
echocardiogram revealed an independently mobile linear structure in the
left atrium. It extended the perimeter of the left atrium and terminated
in the mitral and lateral annulus. Figure 1,Figure 2
A CT angiogram of the chest was performed subsequently. It revealed a
low density mass along the posterior aspect of the left atrium measuring
approximately 8.7 x 7.6 x 5.2 cm, within the mass, high density material
concerning for continued hemorrhage and active expansion was suspected.
Figure 4. A repeat echocardiogram was then immediately performed. The
echocardiogram revealed that a dissection was had enlarged and was
filled with thrombus. Figure 3.
Obstruction of pulmonary venous inflow and mitral flow can result in CHF
and low output syndrome. This is a dreaded complication. In view of CT
scan suggesting ongoing bleeding a decision was made to transfer the
patient to a tertiary care hospital. At the tertiary care facility the
patient remained hemodynamically stable. It was decided to observe the
patient and perform serial imaging. The patient’s intra atrial hematoma
remained stable and did not enlarge further. He was discharged on the
10th postop day.