RESUMO
BACKGROUND: Intravascular lithotripsy is a new method used to treat calcified coronary lesions (CCLs). Percutaneous coronary intervention of CCLs has conventionally been classified as a complex procedure. In the majority of calcified cases, atherectomy is required for sufficient plaque modification prior to stent implantation. Intravascular lithotripsy has been shown to be safe and effective in clinical trials, but as worldwide usage increases, cases of complications are beginning to emerge. CASE SUMMARY: We describe a 71-year-old woman, who after an episode of non-ST-elevation acute coronary syndrome underwent coronary angiography. The culprit vessel was identified to be a severely stenosed left anterior descending artery which was also heavily calcified and tortuous. Intravascular lithotripsy (IVL) was employed for calcium modification prior to stent implantation, but the IVL balloon ruptured during shockwave lithotripsy, resulting in coronary artery dissection. Subsequent management steps and stent deployment resulted in favourable angiographic results. Our findings are further detailed on optical coherence tomography, demonstrating certain features which might predispose to IVL balloon rupture. DISCUSSION: We discuss the mechanism of action during intravascular lithotripsy, and how the shockwaves from the lithotripter modify calcified lesions, whilst keeping soft tissue unharmed. Results from clinical trials and multiple real-world studies have shown that complication rates are low. This case report aims to illustrate how the rupture of an intravascular lithotripsy balloon can result in coronary artery dissection. Optical coherence tomography can help in identifying potential anatomical features which may precede such complications.
RESUMO
BACKGROUND: Intramyocardial dissecting haematoma is a rare complication of myocardial infarction (MI) associated with high mortality rates. Studies and research of this occurrence are limited largely to isolated case reports or case series. CASE SUMMARY: We report a case of late presenting MI, where on initial echocardiogram had what was thought to be an intraventricular clot. However, upon further evaluation, the patient actually had an intramyocardial haematoma, with the supporting echocardiographic features to distinguish it from typical left ventricular (LV) clot. While this prevented the patient from receiving otherwise unnecessary anticoagulation, this diagnosis also put him at a much higher risk of mortality. Despite exhaustive medical and supportive management, death as consequence of pump failure occurred after 2 weeks. DISCUSSION: This report highlights the features seen on echocardiography which support the diagnosis of an intramyocardial haematoma rather than an LV clot, notably the various acoustic densities, a well visualized myocardial dissecting tear leading into a neocavity filled with blood, and an independent endocardial layer seen above the haematoma. Based on this report, we wish to highlight the importance of differentiating intramyocardial haematomas from intraventricular clots in patients with recent MI.