SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Chronic Total Occlusion (CTO) is commonly seen in patients with coronary artery disease (CAD) and is managed medically or with coronary artery bypass grafting (CABG). Some cases with refractory symptoms can be managed with percutaneous coronary intervention (PCI). However, it is associated with complications such as intramyocardial hematoma that can lead to cardiac tamponade. This rare but serious complication can cause fatal outcomes if not recognized early. CASE PRESENTATION: A 60-year-old female presented to our hospital with recurrent substernal chest pain. She had a history of CAD previously managed with CABG. Despite optimal medical therapy and surgical intervention, she reported recurrent symptoms. A left heart catheterization demonstrated CTO for which she underwent PCI to the Right Coronary Artery (RCA). Shortly after the procedure, she developed hypotension requiring ionotropic support. Echocardiogram revealed a hematoma in the free wall of the right atrium surrounded by a complex loculated pericardial effusion which was further confirmed with a Computerized Tomography (CT) scan of the chest. Urgent PCI did not reveal any dye extravasation in the RCA or its branches, ruling out active bleeding. Subsequently, a right heart catheterization was consistent with constrictive physiology without evidence of tamponade. It was decided to conservatively manage the patient without surgical evacuation. The patient had complete resolution of hematoma in the subsequent follow-up visit a month after the procedure. DISCUSSION: CTOs are characterized by complete occlusion of a coronary artery with thrombolysis in myocardial infarction (TIMI) score of 0 or 1, for at least 3 months [1]. Management of CTOs with PCI is associated with a multitude of complications such as coronary perforation, myocardial infarction, need for emergent CABG, and mortality [2]. Perforation of collateral vessels during PCI can lead to the formation of an intramyocardial hematoma. This rare complication has a high risk of mortality as it can potentially cause cardiac tamponade as seen in 0.3% of patients [3]. The majority of these cases present with post-procedural hypotension and hence, an immediate echocardiogram is warranted in such cases. Depending on the stability, an intramural hematoma can be managed conservatively or by surgical decompression. Physicians should be vigilant in suspecting this complication in order to avoid catastrophic outcomes. CONCLUSIONS: Intramyocardial hematoma is a rare and life-threatening complication of PCI in CTO. Urgent evaluation of post-procedural hypotension with an echocardiogram can aid in early diagnosis and prevent fatal outcomes. Reference #1: Stone GW, Kandzari DE, Mehran R, et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I. Circulation. 2005;112(15):2364-2372. doi:10.1161/CIRCULATIONAHA.104.481283 Reference #2: Rigger J, Hanratty CG, Walsh SJ. Common and Uncommon CTO Complications [published correction appears in Interv Cardiol. 2019 Feb;14(1):48]. Interv Cardiol. 2018;13(3):121–125. doi:10.15420/icr.2018.10.2 Reference #3: Slootweg AP, Louwerenburg JW, Mecozzi G, Wagenaar LJ, Verhorst PM. Obstructive intramyocardial haematoma after percutaneous coronary intervention. Neth Heart J. 2012;20(9):376–378. doi:10.1007/s12471-011-0163-8 DISCLOSURES: No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Sana Hyder, source=Web Response No relevant relationships by Christian Mosebach, source=Web Response