Editorial Type: Images in Cardiovascular Medicine
 | 
Online Publication Date: 01 Jun 2016

Giant Intramyocardial Dissecting Hematoma: A Rare Sequela of Subacute Myocardial Infarction

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Article Category: Research Article
Page Range: 277 – 278
DOI: 10.14503/THIJ-15-5142
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A 63-year-old woman with a history of diabetes mellitus, hypertension, and smoking was admitted to our intensive care unit with chest pain of 5 days' duration, new-onset cardiogenic shock, and general malaise. Transthoracic echocardiograms revealed extensive akinesia and a left ventricular ejection fraction of 0.25. At the apical-septal region, we saw a pulsatile cavity with a thin endomyocardial border; this cavity expanded upon systole. However, color-flow Doppler images showed no flow within the cavity. There was mild pericardial effusion. These images were interpreted as intramyocardial dissecting hematoma and underlying intramyocardial hematoma (Fig. 1), the probable result of a subacute anterior myocardial infarction.

Fig. 1. Two-dimensional echocardiograms show the intramyocardial dissecting hematoma. Parasternal A) long- and B) short-axis views show the dissecting, echo-free cavity. C) The 4-chamber view shows the hematoma in the left ventricular apex. D) The subcostal long-axis view reveals increased echogenicity within the cavity, consistent with partially organized thrombi. / DH = dissecting hematoma; LA = left atrium; LV = left ventricleFig. 1. Two-dimensional echocardiograms show the intramyocardial dissecting hematoma. Parasternal A) long- and B) short-axis views show the dissecting, echo-free cavity. C) The 4-chamber view shows the hematoma in the left ventricular apex. D) The subcostal long-axis view reveals increased echogenicity within the cavity, consistent with partially organized thrombi. / DH = dissecting hematoma; LA = left atrium; LV = left ventricleFig. 1. Two-dimensional echocardiograms show the intramyocardial dissecting hematoma. Parasternal A) long- and B) short-axis views show the dissecting, echo-free cavity. C) The 4-chamber view shows the hematoma in the left ventricular apex. D) The subcostal long-axis view reveals increased echogenicity within the cavity, consistent with partially organized thrombi. / DH = dissecting hematoma; LA = left atrium; LV = left ventricle
Fig. 1 Two-dimensional echocardiograms show the intramyocardial dissecting hematoma. Parasternal A) long- and B) short-axis views show the dissecting, echo-free cavity. C) The 4-chamber view shows the hematoma in the left ventricular apex. D) The subcostal long-axis view reveals increased echogenicity within the cavity, consistent with partially organized thrombi. DH = dissecting hematoma; LA = left atrium; LV = left ventricle

Citation: Texas Heart Institute Journal 43, 3; 10.14503/THIJ-15-5142

A computed tomogram confirmed the intramyocardial dissecting hematoma and revealed an apical lesion of the left ventricle (LV), the liquid intensity of which was separated from the LV cavity by a flaccid edge (Fig. 2). We took a conservative approach because the patient's condition was too unstable for cardiac surgery. Death as a consequence of LV failure occurred 2 days after admission.

Fig. 2. Computed tomogram of the chest shows the intramyocardial dissecting hematoma as an apical lesion of the left ventricle with its liquid intensity separated from the left ventricular cavity by a flaccid edge. / DH = dissecting hematoma; LV = left ventricleFig. 2. Computed tomogram of the chest shows the intramyocardial dissecting hematoma as an apical lesion of the left ventricle with its liquid intensity separated from the left ventricular cavity by a flaccid edge. / DH = dissecting hematoma; LV = left ventricleFig. 2. Computed tomogram of the chest shows the intramyocardial dissecting hematoma as an apical lesion of the left ventricle with its liquid intensity separated from the left ventricular cavity by a flaccid edge. / DH = dissecting hematoma; LV = left ventricle
Fig. 2 Computed tomogram of the chest shows the intramyocardial dissecting hematoma as an apical lesion of the left ventricle with its liquid intensity separated from the left ventricular cavity by a flaccid edge. DH = dissecting hematoma; LV = left ventricle

Citation: Texas Heart Institute Journal 43, 3; 10.14503/THIJ-15-5142

Comment

Intramyocardial dissecting hematoma is an extremely unusual rupture of the LV wall that appears as a neocavitation entirely contained within the myocardial wall.1 Diagnosis is often difficult and in most cases is established postmortem. Echocardiography is a useful technique for diagnosing free-wall rupture and monitoring its evolution. In addition, computed tomography of the chest and cardiac magnetic resonance imaging can have diagnostic roles in revealing intact myocardium around an intramyocardial cavity.2,3 In our patient, we first identified intramyocardial hematoma by echocardiography and confirmed that diagnosis by means of computed tomography.

References

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    Vargas-Barron J,
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    Intramyocardial dissecting hematoma and postinfarction cardiac rupture. Echocardiography2013;30(
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    Mejean S,
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    Intramyocardial dissecting haematoma of the left ventricle apex after an anterior myocardial infarction. Eur Heart J2013;34(
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    Pliam MB,
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    Intramyocardial dissecting hematoma: an unusual form of subacute cardiac rupture. J Card Surg1993;8(
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Copyright: © 2016 by the Texas Heart® Institute, Houston 2016
Fig. 1
Fig. 1

Two-dimensional echocardiograms show the intramyocardial dissecting hematoma. Parasternal A) long- and B) short-axis views show the dissecting, echo-free cavity. C) The 4-chamber view shows the hematoma in the left ventricular apex. D) The subcostal long-axis view reveals increased echogenicity within the cavity, consistent with partially organized thrombi.

DH = dissecting hematoma; LA = left atrium; LV = left ventricle

Fig. 2
Fig. 2

Computed tomogram of the chest shows the intramyocardial dissecting hematoma as an apical lesion of the left ventricle with its liquid intensity separated from the left ventricular cavity by a flaccid edge.

DH = dissecting hematoma; LV = left ventricle

Contributor Notes

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030

From: Department of Cardiology, Samsun Education and Research Hospital, 55400 Ilkadim, Samsun, Turkey

Address for reprints: Ugur Arslan, MD, Department of Cardiology, Samsun Education and Research Hospital, Baris Bulvari No: 199, 55400 Ilkadim, Samsun, Turkey, E-mail: ugurarslan5@yahoo.com
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