Case Study
Right ventricular free wall intramyocardial hematoma after coronary bypass
Asian Cardiovascular & Thoracic Annals 21(3) 355–357 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454744 aan.sagepub.com
Prashanth Panduranga1, John Valliattu2 and Mohammed Al-Mukhaini1
Abstract Intramyocardial dissecting hematoma is a rare form of incomplete cardiac rupture usually reported with reference to the left ventricle or interventricular septum. Here we report the case of a 64-year-old man with an isolated right ventricular dissecting intramyocardial hematoma following coronary artery bypass surgery.
Keywords Coronary artery bypass, right ventricle, heart rupture, hematoma
Introduction Intramyocardial hematoma (IMH) is considered to be an incomplete form of cardiac rupture without hemopericardium, accounting for less than 10% of cardiac ruptures.1 IMH is commonly seen after myocardial infarction, chest trauma or surgery, mitral valve replacement, percutaneous coronary intervention, or even spontaneously.1–3 We describe a case of isolated right ventricular (RV) dissecting IMH following coronary artery bypass grafting (CABG).
Case report A 64-year-old man, diabetic, hypertensive, with history of recent anterior non-ST elevation myocardial infarction and severe calcific triple-vessel coronary artery disease, underwent CABG. His preoperative electrocardiogram showed sinus rhythm with complete right bundle branch block, and his troponin T was 0.052 mgL 1 (normal < 0.014 mgL 1). His transthoracic echocardiogram showed concentric left ventricular hypertrophy with a left ventricular ejection fraction of 65%. CABG was performed through a sternotomy incision with moderate hypothermic (32 C) cardiopulmonary bypass and cold antegrade blood cardioplegia. His target vessels were of poor quality. His grafts included a left internal mammary artery graft to the left anterior descending artery, and saphenous vein grafts to the right posterior descending artery, obtuse marginal
artery, and diagonal artery. Perioperatively, he developed significant ischemia in leads II, V4, and V5, with difficulty in weaning off bypass. Internal mammary malperfusion syndrome along with right coronary ischemia was suspected. Hence, he needed 2 more vein grafts, one to the left anterior descending artery and another to the RV branch of the right coronary artery, after which he could be weaned off cardiopulmonary bypass uneventfully. The time on bypass was 120 min, with crossclamp time of 74 min. His electrocardiogram after surgery demonstrated no new changes, but troponin T was increased at 2.2 mgL 1. Immediate postoperative echocardiography did not show any significant abnormality. Repeat echocardiography a week later showed preserved left ventricular ejection fraction of 55%. However, there was a large RV free wall mass that was delineated by an endomyocardial border towards the RV cavity and an akinetic scarred myocardium towards the epicardial border, separated by a small anterior pericardial effusion (Figure 1, arrowheads). This was suggestive of IMH.
1 2
Department of Cardiology, Royal Hospital, Muscat, Oman Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
Corresponding author: Prashanth Panduranga, MRCP (UK), Department of Cardiology, Royal Hospital, Post Box 1331, Muscat-111, Sultanate of Oman. Email: [email protected]
356
Asian Cardiovascular & Thoracic Annals 21(3)
Figure 1. Transthoracic echocardiography (a) in the apical 4-chamber view, (b) modified parasternal views, and (c) demonstrating a large right ventricular free wall echo-dense mass (arrowheads) in a patient with intramyocardial hematoma following coronary artery bypass surgery. Arrowheads: intramural hematoma; LV: left ventricle; RV: right ventricle.
Figure 2. (a) Non-contrast-enhanced computed tomography of the chest, showing a well-demarcated crescent-shaped area of high attenuation across the right ventricular free wall (arrowheads). (b) Contrast-enhanced computed tomography showing the crescentic area as hypo-attenuating relative to the right ventricular cavity, but linearly filled with contrast, indicating rupture and communication with the right ventricle at the apical area (arrowheads).
This immobile mass, measuring 4.9 cm in length and 1.4 cm in width, was noted arising from the RV free wall, extending into the RV cavity, with a high echo density. No mass was seen attached inside the RV endocardium, and no clear-cut communication with the main cavity of the RV could be demonstrated, ruling out thrombus and pseudoaneurysm, respectively. Computed tomography of chest demonstrated a large dissecting IMH of the RV free wall (Figure 2, arrowheads) contained within the RV myocardium. Contrast-enhanced computed tomography showed the crescentic area as hypo-attenuating relative to the RV cavity, but linearly filled with contrast, indicating a small rupture and communication with the RV in the apical area. In view of no significant clinical or hemodynamic abnormality, the patient was managed conservatively and discharged home.
Discussion The pathogenesis of IMH is a hemorrhage dissecting across the spiral myocardial fibers forming a
neo-cavitation limited by the myocardium.1 In patients undergoing cardiac surgery, the proposed mechanism is traumatic atrioventricular disruption leading to rupture of the perforating vessels, resulting in extravasation of blood into the muscle.2 In patient with myocardial infarction, the proposed mechanism of ventricular rupture is the lack of support from infarcted tissue, with destruction of the coronary microvasculature, leading to hemorrhage and formation of a blood-containing mass that dissects, forced by the intracavitary pressure.4 IMH tends to dissect along the spiral muscle fibers and takes its shape along the spiral axis. A dissection entry point can be seen, which differentiates IMH from subepicardial hematoma. Clinical presentation depends on the cause, site, and size of the hematoma. It may be asymptomatic or it may cause severe ventricular dysfunction and cardiac tamponade.1,2 Initially occurring within the myocardial wall, the hematoma may expand, rupture (as noted in this patient), or spontaneously resolve.4 Persistent ST elevation is an important clue suggesting IMH.1,4 However, there may not be any ischemic changes or such changes may appear later.2
Panduranga et al. IMH is usually managed surgically, but conservative management has also been described in stable patients, with spontaneous reabsorption of dissecting IMH during one year of follow-up.4 Dissecting IMH is rarely reported involving the RV, usually following ventricular septal hematoma or rupture related to inferior myocardial infarction.1,3–5 In this patient with RV IMH, perioperative RV ischemia and infarction seems to be the most likely cause of the IMH, probably related to reduced hypothermic protection of the RV during aortic crossclamping or the diffusely diseased calcific right coronary disease necessitating an additional graft. To the best of our knowledge, this is the first description of isolated RV IMH following CABG. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
357 References 1. Harpaz D, Kriwisky M, Cohen AJ, Medalion B and Rozenman Y. Unusual form of cardiac rupture: sealed sub acute left ventricular free wall rupture, evolving to intramyocardial dissecting hematoma and to pseudoaneurysm formation—a case report and review of the literature. J Am Soc Echocardiogr 2001; 14: 219–227. 2. Prashanth P, Mukhaini M and Maddali MM. Intramyocardial dissecting haematoma causing cardiac tamponade: an unusual complication after mitral valve replacement surgery. Ann Card Anaesth 2009; 12: 79–80. 3. Cheng HW, Hung KC, Lin FC and Wu D. Spontaneous intramyocardial hematoma mimicking a cardiac tumor of the right ventricle. J Am Soc Echocardiogr 2004; 17: 394–396. 4. Vargas-Barro´n J, Rolda´n FJ, Romero-Ca´rdenas A, Molina-Carrio´n M, Va´zquez-Antona CA, Zabalgoitia M, et al. Dissecting intramyocardial hematoma: clinical presentation, pathophysiology, outcomes and delineation by echocardiography. Echocardiography 2009; 26: 254–261. 5. Ari H, Tiryakioglu O, Ari S, Bozat T and Koca V. A rare clinical entity: ventricular septal rupture with right ventricular wall dissection after inferior myocardial infarction. Echocardiography 2009; 26: 211–213.
Right ventricular free wall intramyocardial hematoma after coronary bypass
Asian Cardiovascular & Thoracic Annals 21(3) 355–357 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454744 aan.sagepub.com
Prashanth Panduranga1, John Valliattu2 and Mohammed Al-Mukhaini1
Abstract Intramyocardial dissecting hematoma is a rare form of incomplete cardiac rupture usually reported with reference to the left ventricle or interventricular septum. Here we report the case of a 64-year-old man with an isolated right ventricular dissecting intramyocardial hematoma following coronary artery bypass surgery.
Keywords Coronary artery bypass, right ventricle, heart rupture, hematoma
Introduction Intramyocardial hematoma (IMH) is considered to be an incomplete form of cardiac rupture without hemopericardium, accounting for less than 10% of cardiac ruptures.1 IMH is commonly seen after myocardial infarction, chest trauma or surgery, mitral valve replacement, percutaneous coronary intervention, or even spontaneously.1–3 We describe a case of isolated right ventricular (RV) dissecting IMH following coronary artery bypass grafting (CABG).
Case report A 64-year-old man, diabetic, hypertensive, with history of recent anterior non-ST elevation myocardial infarction and severe calcific triple-vessel coronary artery disease, underwent CABG. His preoperative electrocardiogram showed sinus rhythm with complete right bundle branch block, and his troponin T was 0.052 mgL 1 (normal < 0.014 mgL 1). His transthoracic echocardiogram showed concentric left ventricular hypertrophy with a left ventricular ejection fraction of 65%. CABG was performed through a sternotomy incision with moderate hypothermic (32 C) cardiopulmonary bypass and cold antegrade blood cardioplegia. His target vessels were of poor quality. His grafts included a left internal mammary artery graft to the left anterior descending artery, and saphenous vein grafts to the right posterior descending artery, obtuse marginal
artery, and diagonal artery. Perioperatively, he developed significant ischemia in leads II, V4, and V5, with difficulty in weaning off bypass. Internal mammary malperfusion syndrome along with right coronary ischemia was suspected. Hence, he needed 2 more vein grafts, one to the left anterior descending artery and another to the RV branch of the right coronary artery, after which he could be weaned off cardiopulmonary bypass uneventfully. The time on bypass was 120 min, with crossclamp time of 74 min. His electrocardiogram after surgery demonstrated no new changes, but troponin T was increased at 2.2 mgL 1. Immediate postoperative echocardiography did not show any significant abnormality. Repeat echocardiography a week later showed preserved left ventricular ejection fraction of 55%. However, there was a large RV free wall mass that was delineated by an endomyocardial border towards the RV cavity and an akinetic scarred myocardium towards the epicardial border, separated by a small anterior pericardial effusion (Figure 1, arrowheads). This was suggestive of IMH.
1 2
Department of Cardiology, Royal Hospital, Muscat, Oman Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
Corresponding author: Prashanth Panduranga, MRCP (UK), Department of Cardiology, Royal Hospital, Post Box 1331, Muscat-111, Sultanate of Oman. Email: [email protected]
356
Asian Cardiovascular & Thoracic Annals 21(3)
Figure 1. Transthoracic echocardiography (a) in the apical 4-chamber view, (b) modified parasternal views, and (c) demonstrating a large right ventricular free wall echo-dense mass (arrowheads) in a patient with intramyocardial hematoma following coronary artery bypass surgery. Arrowheads: intramural hematoma; LV: left ventricle; RV: right ventricle.
Figure 2. (a) Non-contrast-enhanced computed tomography of the chest, showing a well-demarcated crescent-shaped area of high attenuation across the right ventricular free wall (arrowheads). (b) Contrast-enhanced computed tomography showing the crescentic area as hypo-attenuating relative to the right ventricular cavity, but linearly filled with contrast, indicating rupture and communication with the right ventricle at the apical area (arrowheads).
This immobile mass, measuring 4.9 cm in length and 1.4 cm in width, was noted arising from the RV free wall, extending into the RV cavity, with a high echo density. No mass was seen attached inside the RV endocardium, and no clear-cut communication with the main cavity of the RV could be demonstrated, ruling out thrombus and pseudoaneurysm, respectively. Computed tomography of chest demonstrated a large dissecting IMH of the RV free wall (Figure 2, arrowheads) contained within the RV myocardium. Contrast-enhanced computed tomography showed the crescentic area as hypo-attenuating relative to the RV cavity, but linearly filled with contrast, indicating a small rupture and communication with the RV in the apical area. In view of no significant clinical or hemodynamic abnormality, the patient was managed conservatively and discharged home.
Discussion The pathogenesis of IMH is a hemorrhage dissecting across the spiral myocardial fibers forming a
neo-cavitation limited by the myocardium.1 In patients undergoing cardiac surgery, the proposed mechanism is traumatic atrioventricular disruption leading to rupture of the perforating vessels, resulting in extravasation of blood into the muscle.2 In patient with myocardial infarction, the proposed mechanism of ventricular rupture is the lack of support from infarcted tissue, with destruction of the coronary microvasculature, leading to hemorrhage and formation of a blood-containing mass that dissects, forced by the intracavitary pressure.4 IMH tends to dissect along the spiral muscle fibers and takes its shape along the spiral axis. A dissection entry point can be seen, which differentiates IMH from subepicardial hematoma. Clinical presentation depends on the cause, site, and size of the hematoma. It may be asymptomatic or it may cause severe ventricular dysfunction and cardiac tamponade.1,2 Initially occurring within the myocardial wall, the hematoma may expand, rupture (as noted in this patient), or spontaneously resolve.4 Persistent ST elevation is an important clue suggesting IMH.1,4 However, there may not be any ischemic changes or such changes may appear later.2
Panduranga et al. IMH is usually managed surgically, but conservative management has also been described in stable patients, with spontaneous reabsorption of dissecting IMH during one year of follow-up.4 Dissecting IMH is rarely reported involving the RV, usually following ventricular septal hematoma or rupture related to inferior myocardial infarction.1,3–5 In this patient with RV IMH, perioperative RV ischemia and infarction seems to be the most likely cause of the IMH, probably related to reduced hypothermic protection of the RV during aortic crossclamping or the diffusely diseased calcific right coronary disease necessitating an additional graft. To the best of our knowledge, this is the first description of isolated RV IMH following CABG. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
357 References 1. Harpaz D, Kriwisky M, Cohen AJ, Medalion B and Rozenman Y. Unusual form of cardiac rupture: sealed sub acute left ventricular free wall rupture, evolving to intramyocardial dissecting hematoma and to pseudoaneurysm formation—a case report and review of the literature. J Am Soc Echocardiogr 2001; 14: 219–227. 2. Prashanth P, Mukhaini M and Maddali MM. Intramyocardial dissecting haematoma causing cardiac tamponade: an unusual complication after mitral valve replacement surgery. Ann Card Anaesth 2009; 12: 79–80. 3. Cheng HW, Hung KC, Lin FC and Wu D. Spontaneous intramyocardial hematoma mimicking a cardiac tumor of the right ventricle. J Am Soc Echocardiogr 2004; 17: 394–396. 4. Vargas-Barro´n J, Rolda´n FJ, Romero-Ca´rdenas A, Molina-Carrio´n M, Va´zquez-Antona CA, Zabalgoitia M, et al. Dissecting intramyocardial hematoma: clinical presentation, pathophysiology, outcomes and delineation by echocardiography. Echocardiography 2009; 26: 254–261. 5. Ari H, Tiryakioglu O, Ari S, Bozat T and Koca V. A rare clinical entity: ventricular septal rupture with right ventricular wall dissection after inferior myocardial infarction. Echocardiography 2009; 26: 211–213.
