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Organized intrapericardial hematoma after coronary artery bypass surgery
Journal of Cardiovascular Computed Tomography (2008) 2, 328 –331
Case Report
Organized intrapericardial hematoma after coronary artery bypass surgery Martin Wechsel, MDa*, Dieter Ropers, MDa, Ulrike Ropers, MDa, Sei Komatsu, MD, PhDa, Matthias Regenfus, MDa, Axel Schmid, MDb, Werner Bautz, MDb, Werner G. Daniel, MDa, Stephan Achenbach, MDa Departments of aInternal Medicine II and bDiagnostic Radiology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Germany KEYWORDS: Intra-pericardial hematoma; 64-sliced multidetector computed tomography
Case report A 71-year-old man with a history of a 2-vessel coronary bypass 10 years earlier was admitted because of recentonset atypical chest pain. During angiography and percutaneous revascularization of a distal right coronary artery stenosis, we observed a large structure with calcified borders located lateral to the left ventricle (Fig. 1). Subsequently, transthoracic echocardiography demonstrated an approximately 7 ⫻ 4-cm structure localized lateral to the left ventricle, with systolic and diastolic compression of the left ventricle (Fig. 2). No Doppler flow signal was detectable inside the mass. Contrast-enhanced 64-slice computed tomography (CT; Siemens Sensation 64, Siemens, Erlangen, Germany) revealed an intrapericardial mass with calcified borders and otherwise-homogeneous CT attenuation of 30 HU (Fig. 3). An organized intrapericardial hematoma secondary to bypass surgery was suspected. Magnetic resonance imaging (Siemens Avanto, 1.5 Tesla) confirmed the diagnosis of an intrapericardial hematoma with a similar Conflict of interest: The authors report no conflicts of interest. * Corresponding author. E-mail address: [email protected] Submitted April 8, 2008. Accepted for publication August 9, 2008.
signal intensity to myocardium in T1-weighted spin-echo image and high signal intensity in T2-weighted STIR-image (Fig. 4). No specific therapy was initiated. Features suggesting an intrapericardial hematoma included a typical localization lateral to the left ventricle and atrium, a CT density in the soft-tissue range (approximately 20 –70 HU), the absence of contrast enhancement and presence of “eggshell” calcification, and the presence of epicardial coronary arteries between the mass and the myocardium. These can occur after heart surgery, chest trauma or epicardial injury.1-3 Although most hematomas are absorbed, surgical treatment may be required.
References 1. Fyke FE 3rd, Tancredi RG, Shub C, Julsrud PR, Sheedy PF 2nd. Detection of intrapericardial hematoma after open heart surgery: the roles of echocardiography and computed tomography. J Am Coll Cardiol. 1985;5:1496 –9. 2. Kagaya S, Abe T, Sekine S, Goto Y, Iijima K, Kondoh K. Intrapericardial organized hematoma. A rare complication after open heart surgery. Jpn J Thorac Cardiovasc Surg. 1999;47:291– 4. 3. Hartl WH, Kreuzer E, Reuschel-Janetschek E, et al. Pericardial mass mimicking constrictive pericarditis. Ann Thorac Surg. 1991;52:557–9.
1934-5925/$ -see front matter © 2008 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2008.08.005
Wechsel et al
Organized intrapericardial hematoma after CABG
329
B
A
Figure 1 Coronary angiography demonstrating a large structure with calcified borders located lateral to the left ventricle (arrows). (A) right anterior oblique projection; (B) left anterior oblique projection.
LV
RV
Diastole
LA
Figure 2 Transthoracic echocardiography demonstrated a mass of approximately 7 ⫻ 4 cm (arrows) at the lateral wall with a slight compression of the left ventricle. LA ⫽ left atrium; LV ⫽ left ventricle; RV ⫽ right ventricle.
330
Journal of Cardiovascular Computed Tomography, Vol 2, No 5, September/October 2008
A
B
RV LV RA
LV
LA
RV
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Figure 3 Contrast-enhanced 64-slice multidetector CT showing intrapericardial mass (arrow) with calcified borders. (A) Four-chamber view, long axis. (B) Two-chamber view, short axis. (C) Three-dimensional reconstructions demonstrating the intrapericardial calcified mass adjacent to the left ventricle.
Wechsel et al
Organized intrapericardial hematoma after CABG
A
331 B
RV
RV
LV RA
LV
RA LA
LA
Figure 4 Magnetic resonance imaging showing a circumscribed intrapericardial structure of the left myocardium (arrows), corresponding to an organized and calcified hematoma after aortocoronary bypass surgery. (A) T1-weighted spin-echo image, 4-chamber view. At the lateral wall of the left ventricle a structure appearing similar in signal intensity to the myocardium is shown. (B) T2-weighted STIR-image, 4-chamber view, showing a high signal intensity of the mass. LA ⫽ left atrium; LV ⫽ left ventricle; RA ⫽ right atrium; RV ⫽ right ventricle.
Case Report
Organized intrapericardial hematoma after coronary artery bypass surgery Martin Wechsel, MDa*, Dieter Ropers, MDa, Ulrike Ropers, MDa, Sei Komatsu, MD, PhDa, Matthias Regenfus, MDa, Axel Schmid, MDb, Werner Bautz, MDb, Werner G. Daniel, MDa, Stephan Achenbach, MDa Departments of aInternal Medicine II and bDiagnostic Radiology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Germany KEYWORDS: Intra-pericardial hematoma; 64-sliced multidetector computed tomography
Case report A 71-year-old man with a history of a 2-vessel coronary bypass 10 years earlier was admitted because of recentonset atypical chest pain. During angiography and percutaneous revascularization of a distal right coronary artery stenosis, we observed a large structure with calcified borders located lateral to the left ventricle (Fig. 1). Subsequently, transthoracic echocardiography demonstrated an approximately 7 ⫻ 4-cm structure localized lateral to the left ventricle, with systolic and diastolic compression of the left ventricle (Fig. 2). No Doppler flow signal was detectable inside the mass. Contrast-enhanced 64-slice computed tomography (CT; Siemens Sensation 64, Siemens, Erlangen, Germany) revealed an intrapericardial mass with calcified borders and otherwise-homogeneous CT attenuation of 30 HU (Fig. 3). An organized intrapericardial hematoma secondary to bypass surgery was suspected. Magnetic resonance imaging (Siemens Avanto, 1.5 Tesla) confirmed the diagnosis of an intrapericardial hematoma with a similar Conflict of interest: The authors report no conflicts of interest. * Corresponding author. E-mail address: [email protected] Submitted April 8, 2008. Accepted for publication August 9, 2008.
signal intensity to myocardium in T1-weighted spin-echo image and high signal intensity in T2-weighted STIR-image (Fig. 4). No specific therapy was initiated. Features suggesting an intrapericardial hematoma included a typical localization lateral to the left ventricle and atrium, a CT density in the soft-tissue range (approximately 20 –70 HU), the absence of contrast enhancement and presence of “eggshell” calcification, and the presence of epicardial coronary arteries between the mass and the myocardium. These can occur after heart surgery, chest trauma or epicardial injury.1-3 Although most hematomas are absorbed, surgical treatment may be required.
References 1. Fyke FE 3rd, Tancredi RG, Shub C, Julsrud PR, Sheedy PF 2nd. Detection of intrapericardial hematoma after open heart surgery: the roles of echocardiography and computed tomography. J Am Coll Cardiol. 1985;5:1496 –9. 2. Kagaya S, Abe T, Sekine S, Goto Y, Iijima K, Kondoh K. Intrapericardial organized hematoma. A rare complication after open heart surgery. Jpn J Thorac Cardiovasc Surg. 1999;47:291– 4. 3. Hartl WH, Kreuzer E, Reuschel-Janetschek E, et al. Pericardial mass mimicking constrictive pericarditis. Ann Thorac Surg. 1991;52:557–9.
1934-5925/$ -see front matter © 2008 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2008.08.005
Wechsel et al
Organized intrapericardial hematoma after CABG
329
B
A
Figure 1 Coronary angiography demonstrating a large structure with calcified borders located lateral to the left ventricle (arrows). (A) right anterior oblique projection; (B) left anterior oblique projection.
LV
RV
Diastole
LA
Figure 2 Transthoracic echocardiography demonstrated a mass of approximately 7 ⫻ 4 cm (arrows) at the lateral wall with a slight compression of the left ventricle. LA ⫽ left atrium; LV ⫽ left ventricle; RV ⫽ right ventricle.
330
Journal of Cardiovascular Computed Tomography, Vol 2, No 5, September/October 2008
A
B
RV LV RA
LV
LA
RV
C
Figure 3 Contrast-enhanced 64-slice multidetector CT showing intrapericardial mass (arrow) with calcified borders. (A) Four-chamber view, long axis. (B) Two-chamber view, short axis. (C) Three-dimensional reconstructions demonstrating the intrapericardial calcified mass adjacent to the left ventricle.
Wechsel et al
Organized intrapericardial hematoma after CABG
A
331 B
RV
RV
LV RA
LV
RA LA
LA
Figure 4 Magnetic resonance imaging showing a circumscribed intrapericardial structure of the left myocardium (arrows), corresponding to an organized and calcified hematoma after aortocoronary bypass surgery. (A) T1-weighted spin-echo image, 4-chamber view. At the lateral wall of the left ventricle a structure appearing similar in signal intensity to the myocardium is shown. (B) T2-weighted STIR-image, 4-chamber view, showing a high signal intensity of the mass. LA ⫽ left atrium; LV ⫽ left ventricle; RA ⫽ right atrium; RV ⫽ right ventricle.