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Sumario Vol. 43 - Nº 1 Enero - Marzo 2014


Intrapericardial Hematoma after Myocardial Infarction.
A Rare Pathology

Bonelli Juan Manuel, Girino Cristina,
Arbucci Rosina, Keller Luis, Marino Marcelo

Servicio de Diagnóstico por Imágenes, Resonancia Magnética Cardíaca. Hospital Provincial del Centenario.
(2000) Rosario, Santa Fe, Argentina
E mail

Recibido el 02-DIC-2013 – ACEPTADO después de revisión el 27-Enero-2014..

The authors declare not having conflicts of interest.
Rev Fed Arg Cardiol. 2013; 43(1): 49-51


Print version Imprimir sólo la columna central

Male, 54-year-old patient, addicted to cocaine, who was admitted into the coronary care unit (CCU) on July 27, 2013, with diagnosis of anteroseptal myocardial infarction (Figure 1A), having advanced beyond the first therapeutic window, hemodynamically stable, with no complications. Antithrombotic treatment was started in the CCU (antithrombinic and double platelet antiaggregation), a scheme supported in the OASIS-6 Study [1].

Figure 1a. 12-lead ECG at admittance into the CCU

One day after admittance, echocardiogram was conducted (Figure 1B) that showed septoapical necrosis in the left ventricle (LV) with echodense image in pericardial cavity in lateral predominance of the right ventricle and posterior predominance in the LV, which may correspond to pericardial effusion, in a moderate degree, with abundant fibrin content. Then, antithrombotic therapy was suspended and Cardiac Magnetic Resonance (CMR) was requested to better characterize the extension of infarction, pericardial effusion and assess myocardial viability. The images of CMR (Figures 2A, B, C, D, E, F) show moderate pericardial effusion and image compatible with intrapericardial hematoma.

Figure 1b. • Echocardiogram that shows LV septoapical necrosis
with pericardial effusion

 

Figure 2a. Coronal FSE T1 image.

 

Figure 2b. Coronal FSE T2 image with fat saturation

 

Figure 2c. Angiographic image of 3 right chambers (RA, RV, RVOT)

 

Figure 2d. Angiographic coronal image (SSFP)

 

Figure 2e. Short axis (SA) angiography (SSFP).

 

Figure 2f. Late Enhancement image (LE to confirm myocardial fibrosis)

 

On July 30, the patient presented tachyarrhythmia with narrow QRS (atrial flutter) that quickly reverted with IV amiodarone. Two days later, coronary angiography was requested (Figure 3), which showed total proximal occlusion of the Anterior Descending Artery (ADA).

Figure 3. Coronary angiography that shows total proximal occlusion
of the Anterior Descending Artery (ADA).

Since the patient remained hemodynamically stable, the multidisciplinary medical team followed a waiting management and decided to discharge him, with outpatient clinical control in a cardiology office.

Two months after the index event, control CMR (Figure 4A, B, C) was performed, in which extensive anterior infarction was verified (with parietal thinning and nonviable tissue in transmural fibrosis) with no pericardial effusion and absence of intrapericardial hematoma.

CMR control images at 2 months from myocardial infarction.
 
Figure 4a. Coronal FSE T2 image with fat saturation
(no evidence of effusion or intrapericardial hematoma).

 

Figure 4b. Short axis (SA) angiography (SSFP).

 

Figure 4c. Coronal angiography (SSFP) image showing post-MI
anterior parietal thinning.

In the clinical case presented, the mentioned complication related to the triple antithrombotic therapy, differs pathophysiologically from post-acute myocardial infarction complications, such as Dressler syndrome [2], and cardiac rupture [3,4], or even pericardial effusion complicated with post-traumatic hematoma [3].

Intrapericardial hematoma is an uncommon disease, which should be taken into account when a mass in expansion is found after heart surgery, and even more infrequent, not described in the consulted literature, when there is no history of cardiac surgery, chest trauma, or epicardial injury. Hematomas in chronic expansion may cause mistakes in interpretation, and to consider them as malignant tumors, due to their size, and slow and progressive widening; from there the significance of suspecting of it [5].

 

BIBLIOGRAPHY

  1. Yusuf S, Mehta SR, Chrolavicius S, et al for the OASIS-6 Trial Group. Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA 2006; 295 (13): 1519-30.
  2. Spodick DH.Decreased recognition of the post-myocardial infarction (Dressler) syndrome in the postinfarct setting: does it masquerade as "idiopathic pericarditis" following silent infarcts?.Chest 2004; 126 (5): 1410-1.
  3. SatoshiKainuma, TakafumiMasai, TakashiYamauchi, et al. Chronic expanding intrapericardialhematoma after coronary artery bypass surgery presenting with congestive heart failure. Ann ThoracCardiovascSurg 2008; 14: 52-54.
  4. Cafri C, Shalev A, Zahger D. ST-elevation myocardial infarction caused by coronary artery compression due to localized pericardial hematoma caused by coronary perforation.J Invasive Cardiol 2010; 22(11): E189-92.
  5. Tokue H, Tokue A, Okauchi K, et al. 2-[¹⁸F]fluoro-2-deoxy-D-glucose (FDG) positron-emission tomography (PET) findings of chronic expanding intrapericardial hematoma: a potential interpretive pitfall that mimics a malignant tumor. J CardiothoracSurg 2013; 8: 13.doi: 10.1186/1749-8090-8-13.

 

Publication: March 2014

 
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