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(Circulation. 2007;116:e383-e384.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

Pericardial Effusion With Beginning Cardiac Tamponade Caused by a Spontaneous Coronary Artery Rupture

Thomas Butz, MD; Barbara Lamp, MD; Torsten Figura, MD; Lothar Faber, MD; Hermann Esdorn, MD; Marcus Wiemer, MD; Georg Kleikamp, MD; Dieter Horstkotte, MD

From the Department of Cardiology (T.B., B.L., T.F., L.F., M.W., D.H.), Institute of Radiology, Nuclear Medicine and Molecular Imaging (H.E.), and Department of Thoracic and Cardiovascular Surgery (G.K.), Heart and Diabetes Center North Rhine–Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany.

Correspondence to Thomas Butz, MD, Department of Cardiology, Heart and Diabetes Center North Rhine–Westphalia, Georgstr 11, 32545 Bad Oeynhausen, Germany. E-mail tbutz{at}hdz-nrw.de

A 65-year-old man was admitted to his local hospital with troponin-positive acute coronary syndrome. The patient developed signs of acute heart failure and was immediately transferred to our center.

Echocardiography demonstrated a pericardial mass (8x5 cm) with compression of the right atrium (Figure 1 and online-only Data Supplement Movie I) and a reduced contractility of the posterior left ventricular wall. Magnetic resonance imaging demonstrated a pericardial hematoma that was incompressible, not vascularized, and impinging on the right atrium (Figure 2 and online-only Data Supplement Movie II).

View larger version (87K): [in this window] [in a new window]   Figure 1. Echocardiographic 4-chamber view with pericardial mass (arrow) compressing the right atrium (RA) (see online-only Data Supplement Movie I). LV indicates left ventricle; RV, right ventricle; and LA, left atrium.

View larger version (119K): [in this window] [in a new window]   Figure 2. Magnetic resonance imaging (1.5 T; transversal 4-chamber view; dark blood technique) demonstrated a pericardial hematoma that was incompressible, not vascularized, and compressing the right atrium (RA; see online-only Data Supplement Movie II). RA indicates right atrium; RV, right ventricle; LV, left ventricle; and LA, left atrium.

Coronary angiography revealed 2-vessel coronary disease with 70% stenosis of the ramus circumflexus and subtotal stenosis of the right coronary artery. Surprisingly, the contrast agent squirted out of a ventricular side branch of the right coronary artery, indicating a spontaneous coronary artery rupture with consecutive pericardial contrast depot (Figures 3 and 4 and online-only Data Supplement Movies III and IV). Hemodynamic evaluation showed a mean right atrial pressure of 11 mm Hg.

View larger version (148K): [in this window] [in a new window]   Figure 3. Coronary angiography showing a subtotal stenosis of the right coronary artery. The contrast agent squirted out of a right ventricular side branch (arrow) of the right coronary artery as a sign of a spontaneous coronary artery rupture (see online-only Data Supplement Movie III).

View larger version (124K): [in this window] [in a new window]   Figure 4. Coronary artery rupture and consecutive pericardial contrast agent depot (see online-only Data Supplement Movie IV).

On the basis of these findings, a cardiac operation was performed with evacuation of the pericardial hematoma and bypass grafting. The pericardium was opened and found to be obliterated with coagulated blood, but no continuous bleeding was found around the right coronary artery.

Spontaneous coronary artery rupture without any known underlying condition (eg, Kawasaki’s disease, trauma, or coronary artery dissection) is a very rare disorder and might be underreported because acute bleeding in the pericardium is often lethal and thus not recognized.^1,2

If coronary angiography is performed and the bleeding source can be identified, the coronary vessel might be treated with a coated stent.³ However, pericardial drainage or surgical intervention must be performed in acute hemopericardium with cardiac tamponade.⁴

In patients presenting with acute coronary syndrome and cardiac tamponade, acute spontaneous coronary artery rupture is a possible diagnosis.

	Disclosures

Top Disclosures References

 
None.

	Footnotes

 
The online-only Data Supplement, consisting of Movies I through IV, can be found with this article at http://circ.ahajournals.org/cgi/content/full/116/16/e383/DC1.

	References

Top Disclosures References

 
1. Motoyoshia N, Komatsua T, Moizumia Y, Tabayashib K. Spontaneous rupture of coronary artery. Eur J Cardiothorac Surg. 2002; 22: 470–471.[Abstract/Free Full Text]

2. Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atherosclerotic patients. Eur J Cardiothorac Surg. 2001; 20: 573–576.[Abstract/Free Full Text]

3. Wiemer M, Horstkotte D, Schultheiß HP. Non-surgical management of a perforated left anterior descending coronary artery following cardiopulmonary resuscitation. Z Kardiol. 1999; 88: 675–680.[CrossRef][Medline] [Order article via Infotrieve]

4. Kaljusto M-L, Koldsland S, Vengen OA, Woldbaek PR, Tonnessen T. Cardiac tamponade caused by acute spontaneous coronary artery rupture. J Card Surg. 2006; 21: 301–303.[CrossRef][Medline] [Order article via Infotrieve]

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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 HighWire Citing Articles via Google Scholar Google Scholar Articles by Butz, T. Articles by Horstkotte, D. Search for Related Content PubMed PubMed Citation Articles by Butz, T. Articles by Horstkotte, D. Related Collections Pericardial disease Acute coronary syndromes CT and MRI CV surgery: coronary artery disease Angiography