Case Presentation:
A 77-year-old man with known obstructive coronary artery disease presented to the cath lab for coronary intervention of his left circumflex artery. This was a trifurcation lesion involving the 2nd and 3rd obtuse marginal branch as well as the ongoing AV groove circumflex. Due to significant vessel overlap the guide wires had to be repositioned multiple times, wires were placed in the OM branch and the ongoing Left circumflex. During the procedure one of the wires was inadvertently advanced into the AV circumflex branch. Initial balloon angioplasty was then done with a 2.0 balloon (Euphora, Medtronic) ) A 2.75 x 15 mm stent (Resolute Onyx, Medtronic) was deployed in the obtuse marginal branch and 3.0 x 23 mm stent(Resolute Onyx, Medtronic) was delivered in the proximal left circumflex. Kissing balloon inflations in the two obtuse marginal branches were performed.   Following that, the proximal circumflex was dilated with a 3.0 noncompliant balloon. Final angiographic results were good. Review of the films post procedure suggested that there may have been faint contrast staining from wire in the left atrial circumflex branch.
About an hour following the procedure the patient developed chest discomfort and became hypotensive with a blood pressure of 78/57 mmHg. He was successfully resuscitated with iv fluids. Repeat EKG did not show any significant changes. An urgent echocardiogram was performed. The echocardiogram revealed an independently mobile linear structure in the left atrium. It extended the perimeter of the left atrium and terminated in the mitral and lateral annulus. Figure 1,Figure 2
A CT angiogram of the chest was performed subsequently. It revealed a low density mass along the posterior aspect of the left atrium measuring approximately 8.7 x 7.6 x 5.2 cm, within the mass, high density material concerning for continued hemorrhage and active expansion was suspected. Figure 4. A repeat echocardiogram was then immediately performed. The echocardiogram revealed that a dissection was had enlarged and was filled with thrombus. Figure 3.
Obstruction of pulmonary venous inflow and mitral flow can result in CHF and low output syndrome. This is a dreaded complication. In view of CT scan suggesting ongoing bleeding a decision was made to transfer the patient to a tertiary care hospital. At the tertiary care facility the patient remained hemodynamically stable. It was decided to observe the patient and perform serial imaging. The patient’s intra atrial hematoma remained stable and did not enlarge further. He was discharged on the 10th postop day.