Left atrial compression syndrome secondary to coronary artery perforation: Pathophysiology, diagnosis, and management strategies

Coronary perforation (CP) poses a significant risk of morbidity and mortality, particularly, in patients with a history of cardiac surgery. The occurrence of loculated pericardial effusion presents distinctive challenges in these postcardiac surgical patients. This study delves into the complexities arising from the formation of loculated pericardial effusions subsequent to CP, with a specific focus on the loculated effusion in the posterior wall leading to left atrial compression syndrome. This analysis is dedicated to elucidating pathophysiology diagnostic and treatment strategies tailored for addressing left atrium compression syndrome, providing invaluable insights into the intricacies of diagnosing, treating, and managing this entity in the postcardiac surgical patient.

Percutaneous drainage of a localized biatrial haematoma causing regional tamponade in a patient with prior coronary artery bypass graft surgery: a case report

Background

Regional cardiac tamponade presented as posterior extrapericardial haematomas compressing both atria, with cardiogenic obstructive shock due to inflow abolition is a rare cause of post-percutaneous coronary intervention vascular collapse.

Case summary

We present such a case where computed tomography-guided anterior pericardiocentesis decompressed the atria and restored cardiac output.

Discussion

Prior coronary artery bypass grafting should not be considered protective from cardiac tamponade in patients in whom perforation occurs, because loculated effusions can develop beneath adhesions of the pericardium and compress various cardiac structures (such as the left atrium or the right ventricle); they appear several hours after the intervention and cause atypical haemodynamic manifestations.

Perforation Mechanisms, Risk Stratification, and Management in the Post-Coronary Artery Bypass Grafting Patient

Coronary perforations during chronic total occlusion percutaneous coronary intervention (CTO PCI) is a most frequent major complication and the incidence is significantly higher compared with non-CTO PCI. Patients with prior history of coronary bypass have more major adverse events when perforation occurs compared with patients without prior bypass surgery. In this article, the authors discuss the unique challenges in identification and timely treatment of perforations in patients with prior bypass surgery.

Left Circumflex Artery Rupture with Left Atrial Tamponade and Functional Mitral Stenosis

The growth in percutaneous transluminal devices has enabled operators to tackle more complex, native, and post-bypass surgery anatomy. However, complications such as coronary artery dissection, coronary perforation, retrograde aortic dissection, arrhythmias, and acute coronary syndrome still occur with resulting mortality rates of up to 4.2% in complex interventions. Perforation of the circumflex artery is of particular interest in view of its position and relation to the surrounding cardiac structures. This is a site of potential fluid collection, and as the left atrium is fixed to the parietal pericardium at the entry of the pulmonary veins, fluid in the oblique sinus can accumulate enough pressure to compress the left atrium and the coronary sinus. We present a case of left circumflex artery perforation which demonstrates the physiologic complications of coronary sinus and left atrial compression and the resultant functional mitral stenosis.

Pulmonary artery compression by a localized epicardial hematoma in a patient with idiopathic thrombocytopenic purpura after percutaneous coronary intervention: a case report

Background

The most common complication of coronary artery perforation, a rare complication of percutaneous coronary intervention (PCI), is hemopericardium with cardiac tamponade. However, localized extra-coronary bleeding can lead to epicardial hematoma, which is a rare phenomenon. We report the case of an unusual delayed presentation of post-PCI hematoma with unrecognized guidewire perforation.

Case presentation

A 70-year-old man with idiopathic thrombocytopenic purpura (ITP) and a history of coronary artery bypass grafting (CABG) underwent PCI. A bare metal stent was implanted in left main coronary artery (LMCA) after balloon dilation. The procedure was performed without any complications, and the patient was discharged 5 days later. However, the patient was unexpectedly admitted by ambulance with cardiogenic shock and new-onset chest pain the next day. Echocardiography did not show any wall motion abnormalities, but a large mass on the right ventricle outflow tract was detected. Contrast-enhanced computed tomography showed a hematoma compressing the main pulmonary artery trunk and the right ventricle. The patient developed sudden cardiopulmonary arrest and cardiopulmonary resuscitation was successful. The patient died during emergent surgical removal of the hematoma. Large, dark red clots between the pulmonary artery trunk and aorta were observed. The suspected origin of the epicardial hematoma was blood oozing from the stent site in LMCA.

Conclusion

This is an unusual case with delayed development of localized hematoma following PCI in the absence of guidewire perforation. Furthermore, this case illustrated the potential of occasional critical complications in patients with impaired blood clotting undergoing PCI.

Left Atrial Compression Caused by an Intrapericardial Hematoma after Coronary Artery Bypass Graft Surgery

BACKGROUND

Left atrial compression (LAC) is an uncommon condition that causes left ventricular inflow obstruction. The clinical and pathologic features are similar to those of mitral stenosis. Impaired left ventricular filling may cause hypotension, syncope, or shock. The increased left atrial pressure causes retrograde increase of the pressure throughout the pulmonary circulation with subsequent signs of congestion.

CASE REPORT

An 84-year-old man presented with LAC caused by a focal tamponade related to a pericardial hematoma as a complication of coronary artery bypass graft (CABG) surgery. The formation of the hematoma occurred 3 weeks postsurgery. The echocardiographic study before discharge at day 12 after CABG surgery showed neither a focal hematoma nor a tamponade. The diagnosis was made 6 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intrapericardial tamponade caused by bleeding is a known complication of CABG surgery in the early postoperative stage. However, emergency physicians should be aware that a postoperative hematoma may also present as a focal tamponade because of postoperative adhesion by scar formation. The literature of LAC is limited. The most reported causes of LAC are compression caused by structures of the gastrointestinal tract, followed by thoracic aortic pathology. A Medline search for the terms "left atrial compression and hematoma" and "left atrial compression and intrapericardial hematoma" found only 31 and 4 hits, respectively. We also briefly discuss the import role of bedside echocardiography in the diagnostic process of LAC in the emergency medicine department.

Coronary Artery Perforation following PCI: An Interesting Finding into the Pericardial Space

Coronary artery perforation is a known complication of percutaneous coronary intervention and potentially life threatening. Normally, these perforations are small and localized. We report the successful surgical management of a coronary artery perforation following stent insertion with extrusion of an 8-cm endarterectomy length of the circumflex coronary artery with a brief review of the recent literature.

Coronary perforation and covered stents: an update and review

Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventional cardiology. Coronary perforations are classified as type I (extraluminal crater), II (myocardial or pericardial blushing), and III (contrast streaming or cavity spilling). Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardial drainage. However, type III perforations can be managed with covered stents without need for surgical intervention.