C t l h t (?)C t l h t (?)Coronary extramural hematoma(?) Coronary extramural hematoma(?) caused by perforation treatedcaused by perforation treatedcaused by perforation treated caused by perforation treated conservativelyconservatively

Dr. Prashant JagtapDr. Prashant JagtapMD,DM,FACC,FAPSIC,FSCAIMD,DM,FACC,FAPSIC,FSCAI

Wockhardt Heart Hospital, Nagpur, IndiaWockhardt Heart Hospital, Nagpur, India

l ll lClinical History :Clinical History :GB 42 yrs old male suffered anterior wallGB 42 yrs old male suffered anterior wallGB 42 yrs. old male suffered anterior wall GB 42 yrs. old male suffered anterior wall myocardial infarction (March 2010).myocardial infarction (March 2010).

Th b l d i h I j S kiTh b l d i h I j S kiThrombolysed with Inj. Streptokinase.Thrombolysed with Inj. Streptokinase.

No risk factors for ischemic heart diseaseNo risk factors for ischemic heart diseaseNo risk factors for ischemic heart disease. No risk factors for ischemic heart disease.

ECG : HR 80/min; q with T inversion in leads III, ECG : HR 80/min; q with T inversion in leads III, aVF; T inversion in leads III, aVF, V4aVF; T inversion in leads III, aVF, V4--V6; qs in V6; qs in leads V1leads V1--V3.V3.

2D ECHO : Mild apical septum severe hypokinesia, 2D ECHO : Mild apical septum severe hypokinesia, apex akinetic, EF apex akinetic, EF –– 48%48%

Left coronary angiogramy g g

99 % stenosis in proximal LAD

Left coronary angiogramLeft coronary angiogram

Right coronary angiogramRight coronary angiogram

Right coronary angiogramRight coronary angiogram

RCA – Normal, gives collaterals to LAD, g

Plan : PTCA to LAD

EBU 3.5, 6F guide catheter EBU 3.5, 6F guide catheter

Cross It 100 guide wire.Cross It 100 guide wire.gg

2 X 12 mm balloon dilatation at 8 atm2 X 12 mm balloon dilatation at 8 atm2 X 12 mm balloon dilatation at 8 atm.2 X 12 mm balloon dilatation at 8 atm.

Cross It 100 guide wireg

Balloon dilatation: 2 X 12 balloon

Extravasation of contrast ? extramural hematoma

Patient haemodynamically stable

Prolonged balloon dilatation given.

Bedside echo - no PEBedside echo - no PE

Injection Protamine given to reverseInjection Protamine given to reverseanticoagulation

Patient managed conservativelyPatient managed conservatively

S b t h it l tf lSubsequent hospital course uneventful.

Serial ECG’s no fresh changesSerial ECG s no fresh changes.

Patient discharged on third day.g y

Follow up angio two months later

Healing of perforation

Follow up angio two months laterp g

Healing of perforation

Follow up angio two months laterp g

Residual dissection seen in LAD

Follow up angio two months later

Patient asymptomaticPatient asymptomatic

TMT done subsequently-negative for inducible ischaemiaischaemia

DiscussionDiscussion

Opinion of faculty and experts on Opinion of faculty and experts on angiographic images.angiographic images.angiographic images.angiographic images.Coronary extramural hematoma is a rare Coronary extramural hematoma is a rare complication during PCIcomplication during PCIcomplication during PCI. complication during PCI. Occurs after microOccurs after micro-- or macro or macro --perforation of perforation of coronary arterycoronary arterycoronary artery.coronary artery.Without IVUS it is impossible to diagnose Without IVUS it is impossible to diagnose extramural hematomaextramural hematomaNot all perforations require a covered stent.Not all perforations require a covered stent.p qp q