Abstract 14671: Acute Right Ventricular Failure After Successful Opening of Chronic Total Occlusion in Right Coronary Artery
A 76 year-old man with history of coronary artery disease and recent aortic valve replacement for severe aortic stenosis was referred for an elective PCI with a drug eluting stent (DES) in mid-LCX, and serial lesions in the RCA with CTO of the distal segment that was opened with 3 DES. Final angiographic result was excellent, and he was monitored in recovery unit. 6 hours later, he developed acute left shoulder and chest pain, and ECG showed ST segment elevation in inferolateral leads. He was loaded with prasugrel and emergently taken back to the cath lab with assumed in-stent thrombosis; however, coronary angiogram showed patent stents in RCA and LCX and no significant disease in LAD. Limited TTE in the cath lab showed no evidence of pericardial effusion. He was transferred to CCU with IABP, where he required increasing amount of inotrope, continued to have chest pain, and had a sharp rise in troponin. Further TTE examination showed a large mass measuring 3.5 x 6cm along the space between epicardium and pericardium that resulted in severe compression of RV. Serial images were taken, which showed ongoing enlargement of the mass up to 4 x 13cm in size, with organization of fluid and Doppler evidence of blood flow inside the mass. He was thus taken to the OR for surgical evacuation of the mass, where he was found to have a large intramural hematoma extending from the acute margin of the heart around the apex and onto the LV side of the intraventricular septum. Pericardiectomy was performed to relieve any possible constriction on the right ventricle. Intraop TEE confirmed a return of the RV cavity. Follow-up TTE after 6 weeks showed resolution of the intramural hematoma and the patient did well. In this case, despite the successful revascularization of CTO, it is speculated that there was a micro perforation of RCA, which was exacerbated by the re-loading of antiplatelet therapy causing rapidly enlarging hematoma. In the setting of recent surgery and pericardial adhesions and inflammation, this likely caused severe compression of RV resulting in RV failure and tamponade physiology in the absence of pericardial effusion. Prompt recognition and treatment for RV failure, discovery of RV hematoma and surgical intervention with relief of constriction were all critical in this patient’s care.
- Acute heart failure
- Complete total occlusion
- Percutaneous coronary intervention (PCI)
- Coronary heart disease
Author Disclosures: M. Kawana: None. A. Lee: None. D.H. Liang: None. A. Yeung: None.
- © 2016 by American Heart Association, Inc.