부산대학교 도서관

A 44-year-old lady with acute coronary syndrome underwent percutaneous coronary intervention (PCI) to left anterior descending artery (LAD) via right radial approach. The procedure was complicated by Ellis Type III perforation of mid-LAD after stenting, which was successfully sealed off by cover stents. Post-procedure echocardiogram showed small pericardial effusion (<5 mm) without tamponade. Few hours later, the patient developed severe hypotension (70/40 mmHg) without chest pain which was not responsive to initial fluid challenge. There was no new ST changes on ECG, nor any visible active bleeding and drop in hemoglobin level. Urgent echocardiogram showed increased percardial effusion of around 1 cm, but without any classical features of tamponade. Nevertheless, pericardiocentesis via subcostal approach was done with 150 ml blood-stained fluid drained. Yet the patient remained in severe shock despite addition of inotropes. A second careful search by echocardiogram revealed a large pericardial hematoma (4.5 cm × 2.5 cm) compressing the right ventricular outflow tract (RVOT) to a slit-like passage, which is best viewed in the parasternal short axis view (Figure A). This resulted in obstructive shock. Subsequent computerized tomography also confirmed the presence of periaortic hematoma extending to, and compressing on the RVOT (Figures B). Relook angiogram showed no new perforation, and it was presumed that there has been delayed oozing leading to this presentation. The patient was managed expectantly with volume replacement and gradually recovered. Conclusion: Acute pericardial hematoma at RVOT location can cause cardiac tamponade in the abscene of classical echocardiographic features in usual windows. Clinical correlation with meticulous search are the key to uncover the diagnosis. Figure RVOT Haematoma on ECHO and CT