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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 22  |  Issue : 3  |  Page : 201-205  

Interventricular septal hematoma: A rare complication of retrograde chronic total occlusion intervention


1 Department of Cardiology, Heart Hospital, Doha, Qatar
2 Department of Medical Education, Hamad Medical Corporation, Doha, Qatar

Date of Submission21-Nov-2020
Date of Acceptance26-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Fahad Alkindi
Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_203_20

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   Abstract 


Retrograde percutaneous coronary intervention to chronic total occlusion coronary arteries can have complications due to its complexity. One of its complications is an interventricular septal hematoma which we report here.

Keywords: Complications of chronic total occlusion intervention, Interventricular septal hematoma, retrograde chronic total occlusions approach, septal perforator branches


How to cite this article:
Abdelghani MS, Chapra A, Abed H, Al-Qahtani A, Alkindi F. Interventricular septal hematoma: A rare complication of retrograde chronic total occlusion intervention. Heart Views 2021;22:201-5

How to cite this URL:
Abdelghani MS, Chapra A, Abed H, Al-Qahtani A, Alkindi F. Interventricular septal hematoma: A rare complication of retrograde chronic total occlusion intervention. Heart Views [serial online] 2021 [cited 2021 Nov 28];22:201-5. Available from: https://www.heartviews.org/text.asp?2021/22/3/201/328021




   Introduction Top


Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) within coronary arteries used to be an insurmountable feat until recent years. It has evolved widely with the development of new techniques and equipment as well as the structural training of specialized personnel. Despite this evolution, the risk of complications remains higher than the normal PCI due to the complexity of the lesion and the stiffer equipment used by the operator. We are reporting one of the rare life-threatening complications which is interventricular septal hematoma (IVSH).


   Case Presentation Top


A 44-year-old man from Southeast Asia presented to our hospital complaining of a severe episode of central chest pain on a background of on and off chest pain with moderate exertion that started 3 days before admission. He was known to have suffered a non-ST elevation myocardial infarction 2 months prior with subsequent coronary angiography revealing nonobstructive coronary artery disease. He was for medical treatment with a nonculprit incidental finding of a CTO of the left anterior descending (LAD) artery.

He had an ejection fraction (EF) of 49% at the time and was discharged on optimal anti-ischemic therapy with a plan to evaluate the need of further intervention based on a myocardial perfusion imaging study.

However, the patient presented again to our hospital with unstable angina. Repeat electrocardiography (ECG) and echocardiography revealed the same findings as previous admission. Based on his recurrent anginal symptoms, he was sent for PCI for his CTO of the LAD.

Dual femoral access was obtained with 7F XB 3.5 and AL1 guides in the femoral arteries bilaterally. The antegrade approach was used initially to cross the lesion using the accelerated wire technique that failed. Then we switched to retrograde approach through the collateral septal branches that were being supplied by the posterior descending artery and posterior left ventricular, respectively. Retrograde approach from the right coronary artery-septal used with corsair then finecross microcatheter support. Sion wire was used to sail through septal collaterals. Eventually, the lesion was successfully crossed with pilot 200. The final result of TIMI 3 flow was achieved with 3 overlapping drug-eluting stents from the ostial left main coronary artery to mid-LAD that were postdilated with noncompliant balloon to high pressure. Guidewire perforation of septal collateral was noticed. There was a myocardial blush but no extravasation [Figure 1]. Immediate echocardiogram did not show any evidence of pericardial effusion. The patient was transferred to the coronary intensive care unit for observation with serial echocardiography. Two hours after the transfer, echocardiogram did not reveal any pericardial effusion; however, there was a 2 cm × 1.4 cm mid anterior and posterior IVSH [Figure 2].
Figure 1: Postpercutaneous coronary intervention to chronic total occlusions-left anterior descending showing septal collateral perforation

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Figure 2: TTE apical 4 chambers view showing cystic mass (2.0 cm × 1.4 cm) is visualized in the mid anterior and posterior interventricular septum

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The patient then started to complain of mild chest pain but remained hemodynamically stable without any new ECG changes. However, repeat echocardiogram showed mild increase in the size of the IVSH with partial rupture into the right ventricle [Figure 3]. He was taken for relook coronary angiogram which showed perforation of two septal arteries communicating with the hematoma site with partial rupture of the ventricular septum into the right ventricle [Figure 4].
Figure 3: Cystic mass is increasing in size (2.5 cm × 1.7 cm) is visualized in the mid anterior and posterior interventricular septum which expand in diastole and relatively collapse in systole (dissecting hematoma) new turbulence was noted at RV side of mass with suggested partial rupture of interventricular hematoma

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Figure 4: Relook angiography showing septal perforator branches perforation communicating with a formed sac

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Multiple prolonged balloon inflations strategy at low atmospheric pressure was used first to seal the perforation. However, the blush persisted. Then, it was decided to go for covered stenting using a Graftmaster 2.8 mm × 16 mm stent to the mid distal LAD segment. Postdilation was performed using a Quantum Apex compliant balloon. The main culprit which was the distal septal perforation was successfully sealed, yet there was one septal perforation remaining. Subsequently, intracoronary injection of autologous fat obtained from the groin was considered. The perforated vessel was embolized by the fat particles through corsair microcatheter.

Unfortunately, this method did not work as well mainly due to its very small lumen. The export catheter was then used but it failed as well, due to the inability to track it further down to the perforated vessel due to its bulkiness. Hence, we decided to cover it using a second covered stent. Covered stenting was performed, using a Graftmaster 3.5 mm × 16 mm stent to the mid LAD segment. The end result was achieved by successfully sealing the septal perforator [Figure 5].
Figure 5: Final result with TIMI III flow and sealed perforation

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Immediate post-PCI echocardiography showed no increment in the size of the IVSH and absence of any significant pericardial effusion. Serial echocardiograms over the next few days demonstrated an EF of 51%, and the IVSH seem to be decreasing in size, but there was the persistence of turbulence on the right ventricle suggestive of partial rupture of the IVSH with a peak gradient of 45 mmHg.

The patient, however, remained free of chest pain and hemodynamically stable with no new ECG changes. He was discharged after a week of observation and the final echocardiogram showing partial rupture of IVSH with peak gradient of 22 mmHg and decreasing size of IVSH. Follow-up cardiac magnetic resonance imaging (MRI) showed complete resolution of IVSH and normal LV volumes with normal systolic function (EF 69%). The maximum wall thickness at the mid interventricular septal wall measured 11 mm indicative of a very small interventricular serpiginous track/defect. Neither demonstrable communication to the right ventricular cavity nor significant LV to RV shunts could be further seen [Figure 6].
Figure 6: follow-up cardiac magnetic resonance imaging. (a) 4 chambers late gadolinium enhancement (LGE). (b) Short-axis LGE. Both sections are showing Focal mid septal wall transmural enhancement with no demonstrable communication to the RV cavity

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   Discussion Top


The development of IVSH after PCI to CTO of coronary vessels is a rare complication and occurred in 6.9% of all cases studied in the meta-analysis by El Sabbagh et al.[1] Overall, most incidents of IVSH occur during repairs of the ventricular septal defect (VSD)[2] and other congenital heart defects.[3] However, several cases[4],[5],[6] following retrograde PCI techniques to CTO are found with the typical outcome ranging from being generally favorable[4] to developing cardiac obstructive shock.[5] Further difficulties arise from the lack of guidelines on dealing with such a complication due to its rare occurrence.

The case described above is another example to highlight the need for strict caution during the performance of retrograde PCI's to CTO coronaries. Furthermore, not much knowledge exists on the management of IVSH complicated with partial ventricular septal rupture, which poses a bigger challenge in the postprocedure period. Hence, it is recommended to admit patients with IVSH to the coronary care unit (CCU) for close observation of vital signs, with serial physical examinations and serial echocardiograms to assess for any rapid expansion of IVSH which may predispose the patient to cardiac obstructive shock. The above case highlights the possibility of using covered stents to manage the vessel perforations and perhaps demonstrates the importance of a relook angiogram promptly if there is suspicion of expansion of the hematoma. Finally, MRI can be very helpful in the assessment of IVSH regression or complete resolution.


   Conclusion Top


IVSH is rare complication of retrograde CTO-PCI but potentially dangerous. Guidewire manipulation and dissection in the septal perforator is one of the rare causes like in our case. Although the spontaneous resolution of the IVSH can happen, caution needs to be taken by close CCU observation and serial imaging to detect its progression and the need for intervention. Cardiac MRI is very useful tool to assess its regression and complete resolution.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
El Sabbagh A, Patel VG, Jeroudi OM, Michael TT, Alomar ME, Mogabgab O, et al. Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: A weighted meta-analysis of 3,482 patients from 26 studies. Int J Cardiol 2014;174:243-8.  Back to cited text no. 1
    
2.
Yamazawa H, Takeda A, Nakajima H, Tachibana T, Aoki M. Interventricular septal hematoma following repair of a ventricular septal defect. J Card Surg 2017;32:390-3.  Back to cited text no. 2
    
3.
Yoneyama F, Matsubara M, Sakamoto H, Hiramatsu Y. Interventricular septal hematoma associated with congenital heart surgery: A case report and literature review. J Thorac Cardiovasc Surg 2017;153:e55-7.  Back to cited text no. 3
    
4.
Abdel-Karim AR, Vo M, Main ML, Grantham JA. Interventricular septal hematoma and coronary-ventricular fistula: A complication of retrograde chronic total occlusion intervention. Case Rep Cardiol 2016;2016:8750603. doi: 10.1155/2016/8750603.  Back to cited text no. 4
    
5.
Frisoli TM, Afana M, Mawri S, Hadid M, Sayed L, O'Neill WW, et al. Respect the septal perforator: Septal artery perforation during CTO PCI resulting in massive interventricular septal hematoma and biventricular cardiac obstructive shock. JACC Cardiovasc Interv 2017;10:e91-2.  Back to cited text no. 5
    
6.
Araki M, Murai T, Kanaji Y, Matsuda J, Usui E, Niida T, et al. Interventricular septal hematoma after retrograde intervention for a chronic total occlusion of a right coronary artery: Echocardiographic and magnetic resonance imaging-diagnosis and follow-up. Case Rep Med 2016;2016:8514068. DOI:10.1155/2016/8514068  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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