Author + information
- Received September 4, 2018
- Accepted September 19, 2018
- Published online December 17, 2018.
- Giuseppe Talanas, MDa,∗ (, )
- Roberto Garbo, MDb,
- Giuseppe Nusdeo, MDa,
- Giuseppe D. Sanna, MD, PhDa,
- Ferruccio Bilotta, MD, PhDa and
- Guido Parodi, MD, PhDa
- aClinical and Interventional Cardiology Unit, University Hospital of Sassari, Sassari, Italy
- bInterventional Cardiology Unit, San Giovanni Bosco Hospital of Torino, Torino, Italy
- ↵∗Address for correspondence:
Dr. Giuseppe Talanas, Clinical and Interventional Cardiology Unit, University Hospital of Sassari, Via De Nicola 14, Sassari 07100, Italy.
A 68 year-old man, with multiple cardiovascular risk factors, prior stroke, moderate aortic stenosis, prior coronary artery bypass grafts and percutaneous coronary intervention (PCI) on the mid-circumflex coronary artery, was admitted to our hospital because of severe angina (Canadian Cardiovascular Society grade III) related to a chronic total occlusion (CTO) of the proximal right coronary artery (RCA). Because the J-CTO score was 4 (total length >20 mm, blunt stump, calcifications, prior antegrade attempt), a retrograde approach was chosen. Of note, perforation of the epicardial collateral connecting proximal circumflex artery with distal RCA occurred, and retrograde coil embolization was performed to control bleeding. A limited antegrade subintimal tracking technique was then successfully performed. The RCA was reopened with implantation of 5 overlapping drug-eluting stents. A few hours later, because a routine echocardiogram performed in the coronary care unit showed a huge left atrial intramural hematoma (LAIH) almost completely occupying the chamber, an antegrade coil embolization was performed to seal the other side of the perforation. Computed tomography (CT) confirmed the echocardiographic findings (Figures 1A and 1B, Online Videos 1 and 2). However, the patient was always asymptomatic and hemodynamically stable. After a consultation with cardiac surgeons, a watchful waiting strategy was deemed appropriate. Because the patient developed atrial fibrillation and the CHA2DS2-VASC score was 6, a triple antithrombotic therapy with aspirin, clopidogrel, and dabigatran was prescribed. The patient was strictly followed up in our outpatient clinic. After 9 months, aspirin was stopped, whereas clopidogrel and dabigatran were continued. At 12 months, the patient was asymptomatic. Both echocardiogram and CT showed a considerable spontaneous reduction of LAIH (Figures 1C and 1D, Online Videos 3 and 4).
Coil embolization should be performed from both sides of the perforation (1,2). Time delay from CTO recanalization to antegrade coil embolization explains the extent of LAIH. When LAIH occurs, treatment is extremely difficult. To the best of our knowledge, this is the first reported case of an important spontaneous reduction of a huge LAIH following CTO-PCI despite prolonged triple antithrombotic therapy.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 4, 2018.
- Accepted September 19, 2018.
- 2018 American College of Cardiology Foundation
- Brilakis E.S.,
- Karmpaliotis D.,
- Patel V.,
- Banerjee S.
- Giannini F.,
- Candillo L.,
- Mitomo S.,
- et al.