Year : 2009  |  Volume : 12  |  Issue : 1  |  Page : 79--80

Intramyocardial dissecting haematoma causing cardiac tamponade: An unusual complication after mitral valve replacement surgery

Panduranga Prashanth, Mohammed Mukhaini, Madan Mohan Maddali 
 Royal Hospital, Department of Cardiology and Anaesthesia, PB 1331, Muscat - 111, Oman

Correspondence Address:
Panduranga Prashanth
Royal Hospital, Department of Cardiology and Anaesthesia, PB 1331, Muscat - 111

How to cite this article:
Prashanth P, Mukhaini M, Maddali MM. Intramyocardial dissecting haematoma causing cardiac tamponade: An unusual complication after mitral valve replacement surgery.Ann Card Anaesth 2009;12:79-80

How to cite this URL:
Prashanth P, Mukhaini M, Maddali MM. Intramyocardial dissecting haematoma causing cardiac tamponade: An unusual complication after mitral valve replacement surgery. Ann Card Anaesth [serial online] 2009 [cited 2022 Aug 19 ];12:79-80
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A 29-year-old male with marfanoid features, bileaflet mitral valve prolapse with severe mitral regurgitation and mild left ventricular systolic dysfunction was taken for mitral valve replacement surgery under hypothermic cardiopulmonary bypass (CPB). Approaching through midsternotomy and right atrium, a bileaflet mechanical prosthesis was inserted. After the valve was replaced, CPB was terminated in sinus rhythm and systolic blood pressure of 90 mmHg with minimal inotropic support. Fifteen minutes after terminating CPB, the heart slowed down and SBP dropped to 60 mmHg. This was not responsive to increase in inotropic support. At the same time, it was noticed that the left ventricle (LV) was distending. The surgeons were unable to make out the cause for low cardiac output. On inspection of the heart, there was subepicardial haematoma noticed on anterolateral myocardial wall. There was no obvious bleeding at atrio-ventricular area, no ischaemic changes noticed initially on monitor, and there was no detectable injury to left circumflex artery. An emergency intraoperative transoesophageal echocardiogram (TOE) was done, which revealed normally functioning prosthetic valve but severe global hypokinesia of LV and severe LV systolic dysfunction with ejection fraction of 5-10%. After careful screening, there was a large intramyocardial echodense mass along the anterolateral LV free wall [Figure 1] that was delineated by an endomyocardial border towards the LV cavity and scarred myocardium towards epicardial border. No mass was seen attached inside the ventricular endocardium and no communication with the main cavity of the LV could be demonstrated ruling out thrombus and pseudoaneurysm. Drainage of the subepicardial haematoma was attempted, but there was persistent bleeding. CPB support was re-instituted and the LV was decompressed through a LV vent. The heart was supported on CPB for three hours with no success; the patient remained haemodynamically unstable with evidence of compromised cardiac output and finally expired. Intra-aortic balloon pump support was not attempted, taking into consideration the extensive nature of the haematoma along with very severe LV dysfunction with no evidence of LV ejection despite optimisation with volume and inotropic support.

Intramyocardial dissecting haematoma (IMDH) with or without subepicardial haematoma is a rare, but known complication of acute myocardial infarction, [1] chest trauma, [2] surgery, [3] percutaneous coronary intervention, [4] after cineventriculography [5] or even spontaneously. [6] IMDH is considered to be an incomplete form of cardiac rupture without haemopericardium. Pathophysiologically, an initial bleed may appear 'contained', only to progress in a relentless fashion along naturally occurring dissection planes between the ventricular spiral muscles, dissecting its way through the myocardium, and in the process, avulsing perforating vessels, which in turn bleed further, thereby establishing a self-propagating process. [4] Pathological findings consist of a cavity filled with blood, the outer wall of which is the myocardium and pericardium and the inner wall, which faces the ventricular cavity, is part of the myocardium and endocardium. Clinical presentation depends on the cause for the haematoma. ECG findings are variable; persistent ST elevation is seen in patients who initially present with STEMI, [1] there may be no ischaemic changes, [3] ST elevation can sometime appear late, [5] it can mimic acute myocardial infarction [6] and can present with recurrent ventricular tachycardia. [7] Persistent ST elevation is an important clue in suggesting intramyocardial dissecting haematoma. In the present case, no ST elevation was perceived initially, probably as the coronary arterial blood flow to the LV was intact. However, subsequently, ST wave elevation occurred in the V5 lead. Imaging modalities used to diagnose IMDH are transthoracic and trans-oesophageal echocardiography, [1] computerised tomography scan and magnetic resonance imaging. [8]

The differential diagnosis of IMDH includes prominent ventricular trabeculations, intracavitary thrombi, and pseudoaneurysm. Careful examination of the endocardial and epicardial layers is extremely important, and contrast material is useful to delimit the endocardial borders and distinguish prominent ventricular trabeculations, thrombi, or pseudoaneurysm, whereas colour Doppler ultrasound would detect the presence of a communication with the endocardial or pericardial cavities. [1] Haematoma acoustic characteristics depended on time of evolution. It can be seen as a echodense mass in acute bleed or cystic-like, echo-lucent cavity may be seen adjacent to severely hypokinetic or dyskinetic infarct-related segments. [1] Haemodynamically stable patients are managed conservatively with spontaneous resolution occurring in some cases, [8] and in unstable patients, surgical evacuation with or without glue patch repair has been reported. [3],[4],[7],[9]

This case illustrates an intramyocardial haematoma following mitral valve replacement surgery that was diagnosed intraoperatively by TOE. For an accurate diagnosis, a detailed examination in different views needs to be done as it is possible to be missed if the views are restricted. In the present case, only one view displayed the pathology. The exact cause for this complication in this patient is not known but may be due to injury occurring at the mitral annulus leading to atrio-ventricular disruption followed by rupture of perforating vessels, thereby resulting in extravasation of blood into the muscle and subepicardium.


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