Description of Event or Problem · 0
"LEFT ATRIAL INFLOW AND OUTFLOW OBSTRUCTION AS A COMPLICATION OF RETROGRADE APPROACH FOR CHRONIC TOTAL OCCLUSION: REPORT OF A CASE AND LITERATURE REVIEW OF LEFT ATRIAL HEMATOMA AFTER PERCUTANEOUS CORONARY INTERVENTION". (B)(4). A (B)(6) FEMALE WITH PREVIOUS CABG PRESENTED FOR PCI FOR CONTINUED EXERTIONAL DYSPNEA DESPITE OPTIMAL MEDICAL THERAPY AND A POSITIVE EXERCISE ECHOCARDIOGRAPHIC STUDY SHOWING INFERIOR WALL ISCHEMIA. ANGIOGRAPHY SHOWED PATENT LEFT MAIN AND LEFT CIRCUMFLEX (LCX) ARTERIES WITH OCCLUDED LEFT ANTERIOR DESCENDING (LAD) AND RIGHT CORONARY (RCA) ARTERIES (FIG. 1A). THERE WAS A PATENT LEFT INTERNAL MAMMARY ARTERY TO THE LAD AND OCCLUDED SAPHENOUS VEIN GRAFTS (SVG) TO THE OBTUSE MARGINAL (OM) AND POSTERIOR DESCENDING ARTERY (PDA). THE DISTAL RCA AND PDA RECEIVED WELL-DEVELOPED EPICARDIAL COLLATERALS FROM THE LCX BUT VISIBLE SEPTAL COLLATERALS WERE MINIMAL. AT PCI, THE RCA WAS CANNULATED WITH AN 8-FR JR4 GUIDE CATHETER (CORDIS CORP, MIAMI, FL) AND THE LEFT MAIN WITH AN 8-FR XB3.5 (CORDIS CORP). WITH THE CORSAIR MICROCATHETER (ASAHI INTECC, TOKYO, JP) SUPPORT, A FIELDER XT WIRE (ASAHI INTECC) WAS TRIED INITIALLY AND THEN PILOT 200 (ABBOTT VASCULAR, ABBOTT PARK, IL) TO ANTEGRADELY CROSS THE CTO BUT WIRE PASSAGE WAS UNSUCCESSFUL. THE CORSAIR WITH THE FIELDER XT WAS THEN PASSED TO THE DISTAL LCX AND INTO THE EPICARDIAL COLLATERAL. THE DISTAL END OF THE EPICARDIAL COLLATERAL WAS VERY TORTUOUS AND AFTER MULTIPLE UNSUCCESSFUL ATTEMPTS TO PASS INTO THE DISTAL RCA, THIS APPROACH WAS ABANDONED. DURING ONE ATTEMPT, THE WIRE AND CORSAIR APPEARED TO TAKE AN EXTRAVASCULAR COURSE (FIG. 1B). ANGIOGRAPHY AFTER THIS PASSAGE DID NOT SHOW ANY EXTRAVASCULAR DYE STAINING. THE CORSAIR WITH THE FIELDER XT WIRE WAS THEN PASSED ANTEGRADELY TO THE OCCLUSION WITH A PLAN FOR ANTEGRADE SUBINTIMAL DISSECTION AND RE-ENTRY. AFTER THE WIRE CREATED A SUBINTIMAL TRACK, A CROSSBOSS CATHETER (BRIDGEPOINT MEDICAL, MINNEAPOLIS, MN) WAS USED TO EXTEND THE SUBINTIMAL TRACK TO EMPLOY RE-ENTRY WITH A STINGRAY CATHETER (BRIDGEPOINT MEDICAL). THE CROSSBOSS MOVED ONLY A SHORT DISTANCE FURTHER. THE FIELDER XT WAS EXCHANGED FOR A PILOT 200 WIRE. THE PILOT 200 WIRE PASSED SUBINTIMALLY FOR A SHORT DISTANCE AND THEN RE-ENTERED THE LUMEN. A 1.25-MM SPRINTER BALLOON (MEDTRONIC, SANTA ROSA, CA) DILATED THE FIRST FEW MILLIMETERS OF THE OCCLUSIVE AREA BUT WOULD NOT PASS DISTALLY. THE BALLOON WAS REMOVED AND A TORNUS 2.1-MM CATHETER FOLLOWED BY A 2.6-MM TORNUS (ASAHI INTECC) WAS THEN PASSED TO EXPAND THE MOST DISTAL PART OF THE OCCLUSIVE AREA IN THE SUBINTIMAL ASPECT OF THE WIRE PASSAGE. THE AREA WAS ENLARGED WITH PROGRESSIVELY LARGER DIAMETER BALLOONS FOLLOWED BY IMPLANTATION OF PROMUS DRUG ELUTING STENTS (BOSTON SCIENTIFIC, NATICK, MA) FROM THE DISTAL TO PROXIMAL RCA (FIG. 1C). AT TH END OF THE PROCEDURE, CONTRAST STAINING SUGGESTING PERFORATION WAS NOT APPRECIATED ALTHOUGH SUBSEQUENT FILM REVIEW SHOWED A SMALL CONTRAST LEAK FROM AN EPICARDIAL COLLATERAL BRANCH. THE PATIENT BEGAN TO COMPLAIN OF LEFT-SIDED PLEURITIC CHEST PAIN TOWARD THE END OF THE PROCEDURE. HOWEVER, SHE REMAINED HEMODYNAMICALLY STABLE WITHOUT ELECTROCARDIOGRAPHIC CHANGES OVER THE NEXT 16 HR. PEAK TROPONIN, 19 HR AFTER THE PROCEDURE, WAS 2.76 NG/ML [99TH PERCENTILE URL 0.04 NG/ML]. AT 24-HR POST-PROCEDURE PLEURITIC PAIN, ALTHOUGH STILL PRESENT, HAD DIMINISHED AND DISCHARGE PLANNING WAS STARTED. HOWEVER, SHORTLY BEFORE DISCHARGE, SHE COMPLAINED OF SHORTNESS OF BREATH AND COUGH. HER BLOOD PRESSURE WAS 85/60 MM HG AND PULSE 115 BPM. SHE HAD MINIMAL CRACKLES AT THE RIGHT LUNG BASE WITHOUT OTHER FINDINGS. CHEST X-RAY SHOWED A SMALL RIGHT PLEURAL EFFUSION. PATIENT WAS GIVEN A 500 ML BOLUS OF NORMAL SALINE FOLLOWED BY DRIP AT 100 ML/HR.TRANSTHORACIC ECHOCARDIOGRAM SHOWED A LARGE LA MASS MEASURING 5.3 CM × 4.7 CM ALONG THE POSTERIOR LA WALL BUT NO PERICARDIAL EFFUSION. IT WAS UNCLEAR BY ECHOCARDIOGRAM WHETHER THE MASS WAS INTRA-ATRIAL, INTRA-MYOCARDIAL, OR EXTERNAL TO THE LA. THE MASS HAD A HETEROGENEOUS APPEARANCE WITH SOME ECHOLUCENCY SUGGESTIVE OF A HEMATOMA. A 4-5 MM HG GRADIENT WAS NOTED ACROSS THE MITRAL VALVE (FIG. 2). OVER THE NEXT 24 HR, THE PATIENT BECAME MORE SHORT OF BREATH AND CHEST X-RAY SHOWED WORSENING RIGHT PLEURAL EFFUSION.