LAUSR

A 62-year-old man was transferred to our hospital for coronary angiography. He had been complaining of recent onset angina during exercise. He recognised his symptoms since he underwent a PCI of the left anterior descending (LAD) coronary artery in 2007. There was no chest pain at rest or rise in troponin level. Coronary angiography showed a 50% stenosis in the mid-LAD (Instantaneous wave-free ratio (iFR)1⁄4 0.94, haemodynamically non-significant) and first diagonal branch. Coronary angiography also revealed a chronic total occlusion of the proximal right coronary artery (RCA) with retrograde filling from the septal branches. An antegrade-wiring attempt of the CTO was not successful. Through retrograde dissection re-entry with retrograde access via a septal branch, the distal RCA occlusion was treated with implantation of four drugeluting stents. During the procedure, a small laceration of the septal branch was noted but the patient reported no symptoms nor were there ECG changes or hemodynamic instability (Figure 1). Two hours later, the patient developed acute chest pain, typical for angina in combination with one millimetre ST segment elevation in V1 lead on ECG and frequent monomorphic ventricular extra systole (VES) during monitoring. Two-dimensional transthoracic echocardiography (TTE) visualised a septal haematoma with a maximal diameter of 37mm draining to the right ventricle (RV) (Figure 2). The haematoma was located on the mid portion of the septum and expanded apically. There were no signs of outflow tract obstruction. Conservative management with beta-blockage (bisoprolol 2.5mg) and intravenous (IV) nitrates was initiated, as well as pain relief with paracetamol and a single dose of Morphine 5mg subcutaneously. We observed multiple runs of non-sustained ventricular tachycardia (up to 24 beats). The arrhythmia diminished in frequency and duration and disappeared after 48 h. The patient remained haemodynamically stable and symptoms resolved. The troponin T level peaked at 46mg/l (ULN <0.04). The ST segment elevation in V1 on ECG resolved 3.5 hours after the onset of complaints with the appearance of a pathological Q wave only in V1. Echocardiography the next day showed no increase in size and partial thrombosis of the haematoma (Figure 3). The patient was discharged after 72 h on a low dose of bisoprolol (2.5mg OD) in addition to the aspirin and clopidogrel. Four weeks later, he remained asymptomatic although his general exercise capacity was still limited. TTE showed non-dilated, mildly septal hypertrophic left ventricle with normal global contractility. There was a small akinetic patch in the mid septum correlating with the position where the septal haematoma was previously. There were no other regional contractility changes (Figure 4).