From the Departments of Cardiovascular and Thoracic Surgery (V.N.B.,
A.G.T.) and Cardiology (A.M.N., Y.L.), Seth G.S. Medical College and King
Edward VII Memorial Hospital, Bombay, India.
Correspondence to Dr Vinayak N. Bapat, A 60/574, MIG Colony, Bandra (E), Bombay 400 051, India.
A26-year-old
man was admitted to a private nursing home in December 1995 with the
sudden onset of palpitations. He was diagnosed as having
ventricular tachycardia (monomorphic, left-axis
-60°; rate, 210 bpm) with pronounced hemodynamic
instability. He was electrically cardioverted to sinus rhythm. Clinical
examination revealed a normal heart with no obvious structural heart
disease and no metabolic precipitants. Because he had
repeated episodes of ventricular tachycardia,
he was started on 1000 mg/d amiodarone, which was tapered to
400 mg/d by the end of 1 week. Echocardiographic
results were normal. The patient remained asymptomatic
until February 1996, when he had a similar episode of palpitations. At
this stage, he was referred to us for further management.
Physical examination was normal except for cardiomegaly, which was
confirmed on chest roentgenography.
Echocardiography revealed a uniformly echogenic
mass of 8.5x8 cm in relation to the right ventricle (Fig 1A
The patient underwent surgery on a semiemergent basis;
cardiopulmonary bypass was available. A median sternotomy was
performed. The pericardium was normal, and a diffuse mass that measured
10x9.5x8 cm was seen in relation to the right ventricle (Fig 3A
Although intramyocardial hematoma is very rare, it has been described
as a complication of myocardial infarction.1 The
hematoma may progress along naturally occurring dissection planes
between the ventricular spiral muscles, where it is
described as an "intramyocardial dissecting
hematoma."2 Such a complication has not been
described to have a spontaneous occurrence. In our patient, the dilated
proximal right coronary artery suggests that a long-standing
high-flow situation (probably a coronary arteriovenous fistula)
was the antecedent pathology, which with a catastrophic event such as a
rupture gave rise to the intramyocardial hematoma.
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC 1–267, Houston, TX 77030.
References
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine
Intramyocardial Dissecting Hematoma
), which was visualized as a crescentic
cavity. The proximal right coronary artery was dilated; the
remainder of the chambers were normal. A repeat echocardiogram after 7
days showed mixed echogenicity in the mass (Fig 1B). A diagnosis of
pericardial hematoma was considered. Magnetic resonance imaging of the
heart was performed to confirm the diagnosis, but the scan indicated
the presence of an intracardiac mass (Fig 1C). Cardiac
catheterization was performed to determine the relation
of the coronary vessels to the mass and to assess the right
coronary artery; it revealed a dilated proximal right
coronary artery with an abrupt termination, with the branches
spread over a mass (Fig 2A) and a
negative shadow of the mass compressing the right ventricle (Fig 2B).
At this stage, a diagnosis of intramyocardial hematoma was made. During
this period, the patient had multiple episodes of
ventricular tachycardia, which were terminated
with overdrive pacing.
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Figure 1. Top, Transthoracic echocardiogram of
apical four- chamber view revealing a mass in relation to right
ventricle. RA indicates right atrium; LA, left atrium; and LV, left
ventricle. Middle, Transthoracic echocardiogram of
apical four-chamber view after 7 days of hospitalization revealed a
change in echogenicity of mass compared with that on day 1. Bottom,
Magnetic resonance image of coronal section at mediastinal level
showing a mass (probably a hematoma) in relation to right
ventricle.
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Figure 2. Top, Right coronary artery injection shown
in right anterior oblique view revealing dilated right coronary
artery. Arrow points to feeder vessel of hematoma. Bottom, Right atrial
angiogram in right anterior oblique cranial view showing negative
shadow in relation to compressed crescent-shaped right ventricle.
Pulmonary artery is well opacified. ). Aortic and right atrial purse-string
sutures were made, and an additional purse-string suture was made over
the mass. Needle aspiration was performed, which revealed altered blood
suggestive, by appearance only, of a resolving hematoma. A 2-cm stab
incision was made within the purse-string suture, and 680 g of
blood clots was evacuated. This incision was extended further
laterally. On careful inspection, the intramyocardial nature of the
hematoma was confirmed (Fig 3B), and the source of bleeding was
identified in the region corresponding to the abrupt termination of the
right coronary artery; the bleeding source was closed with a
polypropylene suture. Double breasting of the redundant
ventricular wall was performed. There was improvement in
hemodynamic parameters after evacuation of
the hematoma. The patient made an uneventful recovery. He has not had
further recurrences of ventricular
arrhythmias while on a maintenance dosage of 200 mg/d
amiodarone. Postoperative echocardiography
showed no recurrence of the hematoma and revealed good right
ventricular function, which was also seen on postoperative
cardiac catheterization (Fig 4). The right coronary artery
remains dilated.
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Figure 3. Left, Large globular mass in region of right
ventricle showing coronary vessels stretched over it and areas
of calcification over mass. Right, After evacuation of hematoma, inner
intact and external surgically cut layers of right
ventricular myocardium are seen, confirming
diagnosis of intramyocardial hematoma.
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Figure 4. Postoperative right ventricular
angiogram showing well-opacified and voluminous chamber in comparison
with preoperative compressed crescentic cavity.
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