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(Circulation. 2007;115:e540-e541.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

Loculated Pericardial Hematoma Complicating Complex Coronary Interventions

A Rare but Often Missed Diagnosis?

Alessio La Manna, MD; Didier A. Locca, MD; Sanjay K. Prasad, MD; Carlo Di Mario, MD

From the Cardiovascular Magnetic Resonance Unit (A.L.M., D.A.L., S.K.P.) and Department of Interventional Cardiology (A.L.M., D.A.L., C.D.M.), Royal Brompton Hospital, London, UK.

Correspondence to Alessio La Manna, Via Ala 35, 95123 Catania, Italy. E-mail a_lamanna{at}tin.it

An 86-year-old woman was admitted for elective percutaneous recanalization of a chronic total occlusion of the right coronary artery (Figure, panel 1), already documented in 1999. The occlusion was reopened successfully with a dedicated guidewire (Confianza, ASAHI INTECC, Ltd) and stabilized with implantation of 2 overlapping sirolimus-eluting stents (Figure, panel 2). No contrast staining was observed at the end of the procedure. After 2 hours, the patient developed intense prolonged and continuous chest pain with mild elevation of myocardial enzymes but no clinical signs of cardiac tamponade or ECG changes. Urgent bedside echocardiography, limited by poor echo windows, suggested a small rim of pericardial effusion anteriorly. A cardiovascular magnetic resonance scan was performed, which showed a localized mass (30x40 mm) contained within the pericardium and impinging on the right atrium and right ventricular walls around the right atrioventricular groove but not causing any hemodynamic disturbance (Figure, panels 3 through 5). No evidence of acute infarction by T2 or late myocardial enhancement was detected. The mass was diagnosed as a fresh hematoma around the right coronary artery, and pain subsided under anti-inflammatory treatment. A 5-month follow-up cardiovascular magnetic resonance scan showed complete resolution of the hematoma (Figure, panel 6).

View larger version (121K): [in this window] [in a new window]   1, Baseline right coronary angiography showing proximal chronic total occlusion. 2, Final result after implantation of 2 overlapping sirolimus-eluting stents. 3, Baseline T1-weighted turbo spin echo images of the mass showing variable signal intensity distinct from the myocardium (arrows). 4, Baseline T2-weighted images showing part of the mass hypodense compared with myocardium (arrows). 5, Baseline early gadolinium imaging showing an extracardiac mass in the pericardial space (arrows). 6, Follow-up early gadolinium imaging showing resolution of the mass.

Our case highlights the development of loculated pericardial hematoma formation as a cause of chest pain after complex percutaneous coronary intervention and the risk of missed diagnosis by echocardiography. Cardiovascular magnetic resonance can localize and characterize pericardial masses with its multiplanar cross-sectional nature and the multitude of available sequences, resulting in better assessment of the hemodynamic consequences and therapeutic management of the patient.

	Acknowledgments

 
Sources of Funding

Dr La Manna is the recipient of the research fellowship grant from the European Society of Cardiology. Dr Prasad is supported by CORDA and the British Heart Foundation.

Disclosures

None.

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Issue Highlights
Circulation 2007 115: 2683. [Extract] [Full Text]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by La Manna, A. Articles by Di Mario, C. Search for Related Content PubMed PubMed Citation Articles by La Manna, A. Articles by Di Mario, C. Related Collections Cardiovascular imaging agents/Techniques Catheter-based coronary interventions: stents CT and MRI Chronic ischemic heart disease Related Article