Loculated Pericardial Hematoma Complicating Complex Coronary Interventions
A Rare but Often Missed Diagnosis?
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 (30×40 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).
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.
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.