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CARDIOVASCULAR ANESTHESIOLOGY

A Hypo-Echoic, Intramyocardial Space: Echocardiographic Characteristics of an Intramyocardial Dissecting Hematoma

Ralph Slepian, MD^*, Arash Salemi, MD, James Min, MD, and Nikolaos Skubas, MD, FASE^*

From the Departments of *Anesthesiology, Cardiothoracic Surgery, and Cardiology, Weill Cornell Medical College, New York, New York.

Address correspondence and reprint requests to Nikolaos Skubas, MD, FASE, Department of Anesthesiology, Weill Cornell Medical College, 525 East 68th Street, Rm 302-C, New York, NY 10065. Address e-mail to njs2002{at}med.cornell.edu.

An 82-yr-old woman with a history of renal failure and diabetes was admitted with acute myocardial infarction, and required endotracheal intubation because of low cardiac output. Diagnostic procedures included cardiac catheterization, which revealed nonobstructive coronary artery disease, and a transesophageal echocardiographic (TEE) examination, which revealed a large pericardial effusion without evidence of tamponade, and an area of thickening along the lateral wall of the left ventricle (LV) suggestive of clot. A bedside pericardial paracentesis yielded 400 mL of serosanguinous fluid with no improvement in hemodynamics. A postprocedure TEE examination demonstrated persistence of the thickening along the lateral wall, suggestive of either incomplete fluid drainage or localized thrombus. The patient was taken to the operating room for complete surgical exploration.

Intraoperative TEE examination demonstrated a small LV cavity with no evidence of significant pericardial fluid collection or clot. The lateral LV wall segments were 2.3 cm thick and severely hypokinetic, generated weak echo reflections and had a heterogeneous speckled appearance (Figs. 1 and 2, please see video clips 1 and 2 available at www.anesthesia-analgesia.org). This hypo-echoic cavity was contained between an intact endocardium and an intact, thickened, strongly echogenic epicardium. A distinct tear through the myocardial wall could not be demonstrated by two-dimensional echocardiography or color flow Doppler. Direct examination via sternotomy revealed an intact, ecchymosed LV wall and absence of significant pericardial collection. The presumptive diagnosis of an intramyocardial dissecting hematoma was made, and no further surgical intervention was performed. Postoperatively, the patient was aggressively resuscitated and her cardiovascular status stabilized over the ensuing days. However, on postadmission day 22, she developed Gram-negative rod bacteremia with septic shock and died 4 days later.

View larger version (19K): [in this window] [in a new window]   Figure 1. Transgastric left ventricular (LV) short axis view at the mid-papillary level. The hypo-echoic space is delineated by the dotted line, and is contained within the myocardium. The anterolateral (AL) and posteromedial (PM) papillary muscles, and the epicardium (arrows) are seen. The lateral LV wall segments are thickened, measuring 2.3 cm in diastole.

View larger version (18K): [in this window] [in a new window]   Figure 2. Mid-esophageal 4 chamber view of the left ventricle (LV) and left atrium (LA). The hypo-echoic space (dotted line) is contained between an intact endocardium (arrowheads) and epicardium (arrows), of a markedly thickened lateral LV wall. The presence of pericardial fluid (as seen at the top of the image sector, lateral to the LA free wall) helps in identifying the intact epicardium, thus excluding the diagnosis of pseudoaneurysm.

An intramyocardial hematoma is a type of myocardial rupture, consisting of massive infiltration of blood into and through the myocardial wall. The endocardium and epicardium are intact and the hematoma is contained entirely within the myocardium. The origin of the blood is either from within the ventricular cavity or intramural, but a distinct tear through the myocardial wall is not always identifiable. Formation of an intramyocardial hematoma may result from rupture of intramyocardial vessels into the media, decreased tensile strength of the infarcted area, and acute increase of coronary capillary perfusion pressure. The shape of this hematoma reflects its tendency to dissect along the spiral myocardial fibers (2). This complication occurs after myocardial infarction, thoracic trauma (e.g., severe motor vehicle accident) or with the application of a stabilizer device for off-pump coronary revascularization (3). If associated with acute inferior myocardial infarction, surgical treatment with complete resection and use of graft material for local reinforcement is strongly recommended (2). However, there are little data, after anterior myocardial infarct, although one group reported spontaneous thrombosis in a patient followed for 40 months (4).

Whenever a cavity is found in the LV myocardium, the presence of aneurysm should be investigated. Aneurysms are most commonly seen after myocardial infarction. An aneurysm, either true or false, communicates with the LV cavity. Whereas a true aneurysm is a LV free wall diverticulum comprising all myocardial layers and is often associated with intracavitary thrombosis, a false aneurysm (or pseudoaneurysm) is the result of LV free wall disruption contained by adherent pericardium, and has a high propensity to rupture (4). In doubtful cases, the presence of an intact epicardium along a cavitation (Fig. 2) should rule against the diagnosis of pseudoaneurysm. Beside echocardiography, chest computed tomography and cardiac magnetic resonance imaging can also demonstrate intact myocardium around an intramyocardial cavity and, therefore, diagnose the presence of an intramyocardial hematoma (5).

The intraoperative TEE examination argued against the diagnosis of aneurysm based upon the findings of a continuous, nondisrupted endocardium, lack of communication of the echo-free space with the LV cavity, and an intact epicardium attached to a thin myocardial layer. The cavity was contained entirely within, and among, the myocardial fibers. These findings, if appreciated earlier, might have spared our patient unnecessary surgical intervention.

Footnotes

Accepted for publication July 24, 2007.

This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

REFERENCES

1. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ. Recommendations for Chamber Quantification: A Report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Association of Echocardiography, a Branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440–63[Web of Science][Medline]
2. Harpaz D, Kriwisky M, Cohen AJ, Medalion B, Rozenman Y. Unusual form of cardiac rupture: sealed subacute left ventricular free wall rupture, evolving to intramyocardial dissecting hematoma and to pseudoaneurysm formation—a case report and review of the literature. J Am Soc Echocardiogr 2001;14:219–27[Web of Science][Medline]
3. Mandke NV, Nalladaru ZM, Chougule A, Mandke AN. Intra myocardial dissection hematoma with epicardial rupture—an unusual complication of the octopus 3 stabilizer. Eur J Cardiothorac Surg 2002;21:566–7[Abstract/Free Full Text]
4. Drozdz J, Karprzak JD, Krzeminska-Pakula M. Spontaneous closure (thrombosis) of the intramyocardial dissection: 40-month follow-up. J Am Soc Echocardiogr 2002;15:1023–4[Web of Science][Medline]
5. Muehling OM, Huber A, Schmoeckel M, Behr J. Non-invasive diagnosis of an intramyocardial dissecting hematoma of the left ventricular free wall by cardiac magnetic imaging. Heart 2007;93:71[Free Full Text]

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