Left Atrial Intramural Hematoma Leading to Low Cardiac Output after Heart Transplantation

Abstract

<h3>Introduction</h3> Low cardiac output state in the immediate post heart transplant (HTx) period requires rapid evaluation for aetiology. We describe an unusual mechanism for low cardiac output in a patient with reasonable bi-ventricular function in the perioperative period. <h3>Case Report</h3> A 45 year male underwent urgent HTx (for left ventricular non-compaction with recurrent VT). He had a prolonged bypass time with a 2^nd run for patch repair of the anterior wall of the pulmonary artery anastomosis. In the first six hours, thereafter he developed worsening hemodynamics (CI falling to 1.3, CVP 12-14, MAP 55-60, mPA 19) requiring escalating inotropic support and IABP along with CVVH for lactic acidemia. Transoesophageal echocardiography (TOE) showed a collection posterior to the LA with reasonable biventricular function (Figure 1). There was no gradient across the PA patch; confirmed by PA catheter and TOE. There was significant improvement in hemodynamics (CI 2.1, CVP 15, MAP 80s) on re-opening of the chest, but no collection was found. A diagnosis of intramural hematoma of the posterior wall of the LA was concluded. Subsequently, upon closure of chest an acute deterioration in hemodynamics re-developed. The chest was therefore left open, with improvement. The patient weaned to a single inotrope, with removal of IABP on post op day 2. A TOE on day 3 showed resolution of the intramural hematoma, and the chest was closed without further compromise. <h3>Summary</h3> Intramural hematoma of the LA can cause mass effect with resultant low cardiac output state. Recognition of this rare complication is important in the setting of low cardiac output and good ventricular function following HTx. Management is conservative, after re-exploration, and delayed sternal closure can be used until the hematoma has resolved.