Article ID: CJ-16-0520
A 68-year-old woman with hyperlipidemia was admitted to hospital due to angina pectoris. She had no history of connective tissue disease or autoimmune disease. She received combined therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day) before percutaneous coronary intervention (PCI), but did not receive anti-coagulant therapy.1 Coronary angiography showed severe stenoses of the proximal left anterior descending artery (LAD) and the right coronary artery (RCA). PCI was performed using a 6-Fr IL 3.5 HeartrailTM guiding catheter (Terumo, Japan) via the right radial artery. First, stent implantation was successfully performed using a 3.0-mm×24-mm Nobori stentTM (Terumo) for the proximal LAD. Next, PCI for the RCA was started in the same procedure, but during mechanical power injection (3.0 ml/s) of contrast dye (6 ml) using a 6-Fr IL 3.5 HeartrailTM guiding catheter without a side-hole for the RCA, contrast dye was unexpectedly extended to the atrial septum from the sinus node branch of the RCA without coronary dissection (Figure 1A). Localized contrast dye staining of the atrial septum remained (Figure 1B). The guiding catheter tip was positioned in the appropriate ostium of the RCA, and did not wedge in the coronary orifice without obstructing blood flow. The patient had no chest symptom and no change on electrocardiography. PCI was stopped and absence of pericardial effusion was confirmed on portable echocardiography. Embolization was not performed and the patient was conservatively treated. Transthoracic echocardiography immediately after the procedure showed normal left ventricular wall motion and no pericardial effusion but a low echoic mass (14×17 mm in dimension) in the atrial septum (Figure 1C). Serial echocardiography was carefully observed. Progression of the hematoma, other complications such as cardiac tamponade and heart block were not observed. Contrast-enhanced computed tomography (CT) showed the developm ent of the atrial septal hematoma (ASH) without significant enhancement after contrast injection (Figures 2A,B). Magnetic resonance imaging (MRI) of the hematoma extension was also carried out on the third day after the procedure, showing that it was localized only in the atrial septum, and no extension was observed compared with CT (Figures 2C,D). Transthoracic echocardiography after 2 weeks showed complete absorption of the ASH (Figure 1D). The patient was discharged uneventfully 17 days after the procedure.
(A) Left anterior oblique coronary angiography, showing severe stenosis (dotted red arrow) of the proximal right coronary artery (RCA). Contrast dye was extended to the atrial septum from the sinus node branch (yellow arrows) of the RCA. (B) Persistent contrast dye present in the wall of the corresponding atrial septum (pink arrows). (C,D) Apical 4-chamber transthoracic echocardiography, showing (C) development of a 14×17-mm echogenic mass (dotted orange arrow) compatible with an intramural atrial septal hematoma. (D) After 2 weeks, complete absorption of the intramural hematoma was seen. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
(A) Axial and (B) longitudinal multi-slice computed tomography (CT), showing the atrial septal hematoma without significant enhancement (blue arrows) and its anatomic relationships. (C) Axial and (D) longitudinal T1-weighted magnetic resonance imaging showing a mass with low signal intensity in the center and high signal intensity at the circumference (red arrows) in the atrial septum. The hematoma is localized in the atrial septum, and no extension of the hematoma is observed when compared with CT. Ao, ascending aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
Atria wall intramural hematoma is a rare entity that has been reported after either percutaneous intervention (PCI and catheter ablation)2,3 or surgical procedures.4 Intramural bleeding into the atrial wall has also been reported in association with cardiac amyloidosis,5 mitral calcification,6 myocardial infarction,7 and blunt chest trauma.8 Several spontaneous cases have also been reported without a clear identifiable etiology.9,10 The location, etiology and dimensions of the atrial hematoma are variable. Although a conservative approach has been described,2,7 rapidly growing or obstructive atrial hematoma with insecure hemodynamic change is an indication for cardiac surgery.4–10 Furthermore, heart block may occur if the ASH extends to the A-V node and the bundle.11 Diagnosis is usually performed on multimodality imaging such as echocardiography, CT and MRI.9,10 Transthoracic echocardiography is sometimes inadequate to detect atrial lesions, while cardiac CT and MRI are useful in the assessment and visualization of the expansion of the hematoma from the atrial septum to the atrial wall.
Complex PCI can increase complications such as coronary perforation and dissection, but atrial hematoma following coronary artery perforation during PCI is a rare complication. Coronary artery perforation during coronary angiography is extremely uncommon.12,13 To the best of our knowledge, this is the first report on ASH related to coronary angiography. The main atrial artery is usually the atrial branch that terminates in the sinoatrial node.14 The artery to the sinoatrial node arises from the RCA or the left circumflex artery. It ascends posteriorly along the body of the atrium and gives off branches to both atria and penetrates into the interatrial septum. The mechanism of occurrence of extravasation of contrast is not clear. Although we did not perform intravascular ultrasound or optical coherence tomography for the proximal RCA,15 narrowing, dissection and intimal flap of the proximal RCA on CAG were not observed. Therefore, it is possible that ASH was caused by the perforation of a peripheral microvessel of the atrial artery, not dissection from the ostium to the distal RCA, during coronary angiography using mechanical power injection. We should be aware of the risk of ASH even during coronary angiography.
We thank the staff of the Department of Cardiology, Fukuoka Wajiro Hospital, for their excellent assistance.
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