CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 222 AFRICA 1D). CTA showed a mass approximately 7.3 × 5.1 cm within the left atrium (Fig. 2). Emergency transthoracic echocardiography demonstrated a large haematoma adjacent to the left atrium without any pericardial effusion. During the echocardiography procedure, the patient experienced obvious hypoxia, including increased breathing frequency and a reduction of oxygen saturation to approximately 90% under the support of mask oxygen supplied at a rate of 6 l/min. Thepatientwas referred tocardiac surgery for anemergency left atrial thrombectomy, and LatD was diagnosed intra-operatively. The operation was performed under general anaesthesia and cardiopulmonary bypass (CPB). Significant bloody pericardial effusion was seen, and the left atrium appeared bruised in its entirety. A large haematoma was seen within the posterior atrial wall after the left atrium was opened via an interatrial sulcus incision. The endocardial layer of the left atrium had been separated from the left atrial wall (Fig. 3A). No obvious left atrial endocardial rupture was found, and the structure and function of the mitral valve were normal. Blood clots were carefully removed from the endocardium and epicardial cavity. After repeated irrigation of the left atrium, the left atrial endocardium and epicardium were sutured intermittently with 4-0 polypropylene sutures, and a drainage window was opened at the proper location of the endocardium to allow for decompression (Fig. 3B). The left atrium was sutured continuously with 4-0 polypropylene sutures. The patient was successfully weaned from CPB. The total operative time was 150 min, of which 73 min involved CPB, and the time required for aortic clamping was 53 min. The patient recovered uneventfully and was discharged one week after the operation. During follow up, transthoracic echocardiography showed no significant change in cardiac function, and coronary CTA showed no new haematoma in the left atrium (Fig. 4). Discussion LatD is a potential complication of cardiac surgical procedures, including mitral valve repair or replacement. Recently, increasing numbers of cases of LatD have been reported in concert with the growth of PCI. It is important to note that distal coronary artery perforation, which is generally believed to be a major initiator of LatD, occurs in 0.3 to 0.6% of all PCI procedures, as demonstrated by a comprehensive review of more than 50 000 PCI cases.6 Distal wire perforations are an especially common risk in long or complicated procedures that require repeated application of an antegrade approach or a retrograde operation through the epicardial collateral vessels.7 This complication is especially relevant to patients with total occlusion of the coronary artery.8 In our case, the guide wire passed through the occlusion site of the distal right coronary artery under the guidance of the retrograde guide wire in the epicardial collateral vessels of the right coronary artery. After stent implantation, angiography showed a slight staining of the surrounding myocardium without Fig. 4. A coronary CTA performed one month after the event indicated that the left atrium was well filled with no residual haematoma. orifice of left inferior pulmonary vein mitral valve haematoma orifice of left superior pulmonary vein orifice of right superior pulmonary vein orifice of right superior pulmonary vein endocardium window drainage Fig. 3. A. Simulation of intra-operative findings. The posterior atrial wall had suffered a large haematoma, which partially blocked the entrance of the bilateral pulmonary veins. The endocardial layer of the left atrium was separated from the left atrial wall. B. Schematic diagram of surgical operation. After removal of the haematoma, the endocardial false lumen was closed by 4-0 polypropylene sutures with pledgets to protect the entrance of the bilateral pulmonary veins. An endocardium drainage window was opened at the proper location within the endocardium for decompressing. A B
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