CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 220 AFRICA Case Report Surgical treatment of left atrial dissection caused by percutaneous coronary intervention Shiqiang Wang, Jiakan Weng, Fan He, Ximing Qian, Yu Liu, Huaidong Chen Abstract Left atrial dissection (LatD), also known as left atrial intramural haematoma, is a rare condition that requires rapid diagnosis and frequently calls for timely surgical intervention. Diagnosis can be challenging because of a lack of definitive clinical criteria, and a patient’s situation can be complicated by co-morbidities, including unstable haemodynamics. We surgically repaired a case of LatD related to percutaneous coronary intervention (PCI). The operation went smoothly, and the patient was discharged one week after the operation. For LatD patients with co-morbidities, especially haemodynamic disorders, active surgical intervention is recommended. Keywords: left atrial dissection, percutaneous coronary intervention, intramural haematoma Submitted 13/4/21; accepted 13/9/21 Published online 28/9/21 Cardiovasc J Afr 2022; 33: 220–224 www.cvja.co.za DOI: 10.5830/CVJA-2021-045 Left atrial dissection (LatD) involves separation of the walls of the left atrium due to aberrant blood flow, creating a blood- or thrombus-filled chamber that may involve communication into the true left atrium.1 LatD can have surgical or non-surgical origins.2 Cases arising from surgical procedures are mainly associated with mitral valve surgery (repair or prosthetic intervention), aortic valve replacement, coronary artery bypass grafting, cardiac mass excision and pulmonary vein cannulation. LatD can occur spontaneously or can have other non-surgical causes, including myocardial infarction, ablation, chest trauma or endocarditis.3,4 Another non-surgical cause of LatD involves complications due to percutaneous coronary intervention (PCI).5 In fact, recent rapid developments in PCI technology have been correlated with an increasing incidence of LatD. Here, we report on a case of acute LatD following PCI, and we discuss its pathogenesis, diagnosis, management and prognosis. Case report A 57-year-old male patient of our hospital’s Cardiology Department underwent percutaneous intervention due to recurrent angina. This angina was caused by obstruction of a stent that was implanted following acute myocardial infarction four years prior. No obvious pathological results were found in pre-operative transthoracic echocardiography and haematology. Coronary angiography demonstrated a complete occlusion of the right coronary artery due to stent thrombosis but no obvious stenosis of the left coronary artery (Fig. 1A). Cardiologists repeatedly failed to pass a catheter through the right coronary artery via an antegrade approach. After several unsuccessful attempts, a SION guidewire was inserted in a retrograde manner through a collateral of the posterior descending branch. Then, the antegrade guide wire was passed through the occlusion site of the distal right coronary artery with the guidance of the retrograde guide wire in the epicardial collateral vessels of the right coronary artery (Fig. 1B). A PROMUS Element drug-eluting stent, measuring 2.25 × 28 mm, was placed in the distal right coronary segment of the proximal left ventricular branch. An EXCEL drug-eluting stent, measuring 3.5 × 24 mm, was placed in the middle and distal segment of the right coronary artery, overlapping with the anterior stent by 1 mm. Angiography demonstrated that stent expansion was satisfactory and coronary flow was unobstructed, but the myocardium was slightly stained (Fig. 1C). There was no obvious pericardial effusion per echocardiography. The patient was sent to the coronary care unit (CCU) after the procedure. Unfortunately, the patient felt obvious chest pain that could not be relieved by nitroglycerin one hour after entering the CCU. Because acute embolism of the coronary stent was a possibility, coronary angiography was repeated. Meanwhile, in order to exclude iatrogenic injury of the aorta, computed tomography angiography (CTA) of the entire aorta was also performed. Coronary angiography showed that coronary blood flow was comparable to that seen in the initial angiography, and no thrombosis was found in the stent, but contrast extravasation was observed in a distal branch of the right coronary artery (Fig. Department of Cardiac Surgery, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China Shiqiang Wang, MD Jiakan Weng, MD Fan He, MD Ximing Qian, MD Yu Liu, MD Huaidong Chen, MD, 3317025@zju.edu.cn
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