Coronary Artery Perforation, Subepicardial Hematoma, and Cardiac Tamponade After Complex Percutaneous Coronary Intervention

Abstract

This report presents the case of fissured subepicardial hematoma and cardiac tamponade after coronary artery perforation during a complex percutaneous intervention. Surgical therapy was required to achieve hemostasis because a percutaneous sealing result was insufficient. Prompt recognition and cardiac surgery availability are essential for patient survival in such situations. ( Level of Difficulty: Beginner. )

Iatrogenic coronary artery perforation resulting in intramyocardial haematoma and ventricular pseudoaneurysm

“…This can lead to development of cardiac haematomas (subepicardial, intramyocardial) which have a high fatality rate 3. These haematomas can either be treated to offset any haemodynamic compromise or monitored till they resolve 4. Our case is unique in that we present both intramyocardial haematoma and ventricular pseudoaneurysm as potential complications of iatrogenic CAP.…”

Right ventricular hematoma: A rare but potentially fatal complication of percutaneous coronary artery intervention

“…It may be asymptomatic and self‐limiting, but it may also lead to an obstructive shock due to inflow or outflow obstruction of the right ventricle with rapid circulatory collapse and sometimes even fatal outcome. Coronary perforation cannot only lead to RV hematoma, but also to left ventricular, left atrial, and septal hematomas with similar consequences 9–12 . With the increasing number of complex PCIs including CTO procedures, these complications might be inevitable and will continue or even increase in frequency 2 .…”

“…In the first place, it is of importance to understand the location of a cardiac wall hematoma caused by coronary perforation. In previous reports, different definitions are used, such as “intramural hematoma,” “intramyocardial hematoma,” “subepicardial hematoma,” or “localized hematoma.” 4–10 On echocardiography the exact location is difficult to discriminate. Based on the CT scan in Case 1, the hematoma is localized between the visceral pericardium (=epicardium) and myocardium, in other words, “subepicardial.” A previous report demonstrated an entire intramyocardial hematoma on cardiac CT and MRI after coronary perforation during RCA PCI 4 .…”

“…Coronary perforation cannot only lead to RV hematoma, but also to left ventricular, left atrial, and septal hematomas with similar consequences. [9][10][11][12] With the increasing number of complex PCIs including CTO procedures, these complications might be inevitable and will continue or even increase in frequency. 2 Therefore, raising awareness for this complication is important.…”

“…In previous reports, different definitions are used, such as "intramural hematoma," "intramyocardial hematoma," "subepicardial hematoma," or "localized hematoma." [4][5][6][7][8][9][10] On echocardiography the exact location is difficult to discriminate. Based on the CT scan in Case 1, the hematoma is localized between the visceral pericardium (=epicardium) and myocardium, in other words, "subepicardial."…”