SPC365

Coronary perforation with recurrent cardiac tamponade: always check the other side

Session: Prémio Melhor Caso Clínico
Speaker: Pedro Brás

Congress: CPC 2022
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Session Type: Prémios
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Authors: Pedro Garcia Brás; Luís Morais; Tiago Mendonça; José Viegas; André Grazina; António Fiarresga; Duarte Cacela; Rui Cruz Ferreira
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">The authors present the case of a 54 year old female patient with a </span><span style="font-size:12.0pt">late-presenting inferior ST segment elevation myocardial infarction (STEMI). The echocardiogram (TTE) showed preserved biventricular function, with inferior and posterior wall hypokinesis. The patient was administered ticagrelor 180 mg and acetylsalicylic acid 250 mg.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">The invasive coronary angiography (ICA) revealed occlusion of the distal right coronary artery (RCA), with obstructive disease in the proximal and mid segments and a TIMI 2 flow in the posterior descending artery (PDA) (Figures). There was also an intermediate lesion of the mid left anterior descending artery (LAD). Percutaneous coronary intervention (PCI) of the proximal (3x38 mm drug-eluting stent [DES]) and distal RCA (2.5x26 mm DES) segments was successfully performed.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">Despite the initial favourable result, three hours later angina and dyspnea recurred and significant hypotension and tachycardia developed. A prompt ECG revealed sinus tachycardia and low QRS voltage. Bedside TTE ruled out mechanical complications of MI but showed a severe pericardial effusion (PE), with collapse of the right heart chambers consistent with tamponade physiology, confirming the diagnosis.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">Immediate intravenous fluids were started and percutaneous pericardiocentesis was performed, with a drainage of 1400 mL of hematic effusion. The patient was submitted to a new ICA which revealing adequate stent patency and the apparent cause of the PE: contrast leak to the pericardium indicative of coronary perforation of a distal branch of the PDA. After prolonged balloon insufflation, a covered stent (</span>2.5x15 mm<span style="font-size:12.0pt">) was implanted from the distal RCA (intrastent) to the posterolateral artery, thus excluding the PDA (small caliber artery) to control the perforation. Repeated TTE did not show significant PE.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">Later that day, hypotension recurred with altered mental status and i</span>mmediate TTE revaluation confirmed recurrence of cardiac tamponade. Mechanical ventilation and vasopressors were started. <span style="font-size:12.0pt">Manual syringe suction from the pericardial drainage was performed, with successful drainage of 250 mL of hematic PE.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">New ICA was performed, with a RCA injection revealing no signs of coronary perforation. Finally, a LCA injection showed the principal cause for the recurring PE: collateral vessels originating from the LAD to the occluded PDA, with visible contrast leak to the pericardium.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">After multidisciplinary discussion, the patient was submitted to surgical inferior pericardial patch implantation and glue, with favourable result, achieving hemodynamic stability. The patient was discharged safely one week later, with minimal PE.</span></span></span></p>

<p><span style="font-size:11pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="font-size:12.0pt">This case details the importance of keeping in mind the possible complications of acute coronary syndromes, such as mechanical complications, as well as possible iatrogenic complications of PCI, like coronary perforation, and always perform a complete ICA.</span></span></span></p>