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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017

e10

AFRICA

anti-anginal therapy, including intravenous nitroglycerin and

morphine sulfate. In addition, we reversed the effects of heparin

with protamine sulfate.

On day three of the follow up, cardiac computed tomography

revealed thickening of the lateral wall of the myocardium, a

radiolucent centre without contrast dye, and bilateral pleural

effusions with no pericardial effusion (Fig. 2B, C). The patient

developed transient atrial fibrillation and dyspnoea on the third

day. Sinus rhythm was achieved with intravenous amiodarone,

and the heart failure symptoms and findings disappeared with

diuretics.

The patient did not complain of chest pain or arrhythmia

after the third day, and she was discharged on the sixth day of

follow up. There was no haematoma in the lateral wall of the

left ventricle but this part of the left ventricle was akinetic in the

control echocardiography after 45 days.

Discussion

DIH can occur as a complication of myocardial infarction, PCI

and cardiac surgery.

1

Prediction and diagnosis of DIH is very

difficult after PCI and cardiac surgery. There are a few cases of

DIH after PCI reported in the literature.

2

Continued leakage of blood from the coronary artery after

any kind of perforation and avulsion of the vessel can lead to

dissection of the myocardium and it is characterised by dissection

between the spiral planes of heart muscle, including laminated

thrombi, myocytes and fibrous tissue.

2

Self-propagation of the

haematoma leads to more expansion, and it can be complicated

by myocardial wall rupture.

3

Patients with previous cardiac surgery may have a self-

limiting DIH because of pericardial adhesions to the epicardium.

Therefore, these patients may be protected from myocardial

rupture.

4,5

Since it is a rare situation, management of DIH is challenging

in evidence-based medicine. Conservative management of DIH

is associated with a mortality rate as high as 90 to 100%.

2

Management strategies depend on the location and/or extent of

the DIH.

Left ventricular apical location of the DIH has higher

spontaneous reabsorption rates so conservative management is

preferable for this position. Evacuation of the DIH and surgical

Fig. 2.

A. Transthoracic echocardiography. B, C. Axial and sagittal computed tomography sections of the heart. Intra-myocardial

haematoma is seen in both echocardiography and computed tomography (asterisk). LV, left ventricle; LA, left atrium.

A

B

C

Fig. 1.

A. Coronary angiography before PCI. B. ECG after PCI. C. Control angiography. Significant stenosis is seen in the circum-

flex artery (A) and there is no contrast dye leakage in the control angiography (C) in the right caudal position. There is ST

segment elevation in D1 and aVL deviations, suggesting a new-onset acute coronary syndrome.

A

B

C