P02-7 - Hemodynamic deterioration after percutanuous coronay intervention in a patient with previous CABG

Abstract

A 69 year old patient, with a past medical history of ischemic heart disease, hypertension, type 2 diabetes mellitus and coronary artery bypass grafting 18 years previously, has been admitted in our institution for recurrent stable angina due to an occlusion of his obtuse marginal (OM) graft. In catheter lab, after several attempts, the saphenous vein graft to OM branch was stented and flow restored but during the procedure, the patient developed dyspnoea with hemodynamic compromise. An intra-aortic balloon pump was inserted improving the clinical features. At the end of the procedure the patient was transferred to the high dependency unit, but 45 minutes later he suffered a cardiac arrest requiring one cycle of cardiopulmonary resuscitation with epinephrine and was underwent tracheal intubation. Following return of spontaneous circulation, inotropes were commenced and the patient was transferred to the intensive care unit. A transoesophageal echocardiography (TOE) at the time revealed a localized pericardial collection with cardiac tamponade and the chest x-ray showed a diffuse ground glass opacification of both lungs, suggestive of pulmonary oedema. The patient was urgently transferred to theatre for surgery for pericardial drainage. On opening the pericardium via a left thoracotomy, the surgeon found no collection. At the TOE, the anaesthetist then presumed the diagnosis of sub-epicardial hematoma occupying a large part of the wall of the left atrium. A dilated right ventricle is also seen, with systolic impairment and left sided shift of the interventricular septum. The surgeon could then identify an area of bruised tissue around the right atrium-ventricular grove and the wall of the left atrium overlying the hematoma visualised on TOE. A small incision was then made into the atrial wall at that point allowing suction of the clot with subsequent relief of the obstruction.