P415 THE STRANGE CASE OF A LATE POCKET HEMATOMA

Abstract

Abstract Case report: male, 85 years old. Hospitalization in 2013 at the Ancona Cardiology Department due to severe left ventricular dysfunction. In the history of pulmonary lobectomy results (2005). ⦁ EKG: PR 220 msec, left bundle block ⦁ coronary angiography: ed ⦁ blood analysis: hemoglobin 15 g/dl, PLT 229/mm3, Creatinine 1.1 mg/dl, Glycemia 84 mg/dl. ⦁ Echocardiogram: severe LV dilatation (LVVT 105 ml/m2) and severe reduction of LVEF due to diffuse hypokinesia. Strain test for possible CRTD implant: no intraventricular asynchrony. A single–chamber ICD was implanted in primary prevention in the left subclavicular site ( antibiotic prophylaxis with ciprofloxacin 1 g). Chest x–ray showed correct lead placement, no pneumothorax. The patient was discharged with antibiotic therapy. Since then he has continued the cardiological follow–up on a regular basis (cardiological visit + six–monthly ICD check). It should be noted that NOAC (Rivaroxaban 20 mg) was introduced in 2020 for the detection of atrial fibrillation. In December 2021, at last ICD check: no arrhythmic events, no alterations of the electrical parameters, good condition of the PM pocket. On 09.01.22, access to the ER due to the appearance of elastic swelling of the pocket. Apiretic. The ER doctor performed ultrasound (non–trabecular subcutaneous effusion) and proceeded to aspirate 15 cc of serum–blood fluid. He discharged the patient with appointment at the PM clinics. Cardiological consultation or blood chemistry tests were not carried out. On 19.01.22 the patient presented to our clinics: voluminous elastic swelling of the soft tissues overlying the pocket, which appeared floating. No local inflammation or cutaneous ischemic suffering. No solutions of continuity in the skin. No pain. He also reported not having taken the prescribed antibiotic. He denied fever or trauma in the previous weeks. As the blood chemistry tests were not performed in the ER, the blood count (Hb? WBC?), renal function (rivaroxaban overdose?), inflammation indices were not known (CRP? PCT?), coagulation function (spontaneous INR?). Urgent hospitalization was scheduled for surgical revision, pocket decompression, swab culture and blood cultures. Conclusions The hypotheses are hematoma during NOAC, pocket infection or cystic hygroma. After surgery evidence of organized hematoma of tissue adjacent to the pocket with negative blood cultures.