A 61-year-old woman arrived at our emergency department because of the appearance of intense palpitations for 3 days. She denied cardiovascular risk factors or a previous cardiac disease, did not assume pharmacological therapy, and reported only a recent domestic accidental fall without apparent complications. The heart rhythm appeared tachycardic and irregular, and the remaining vital parameters were normal with a good hemodynamic compensation (systemic blood pressure 135/75 mmHg, SaO2 98%). Electrocardiogram reported atrial fibrillation with high ventricular response (136 bpm). The blood tests were all normal, except for a mild and nonspecific increase in the high-sensitivity troponin T.\nThe patient underwent a cardiology consult in order to plan the following therapy procedure. Subsequent transthoracic echocardiogram revealed a dilated LA with an interior septum which extended across the longitudinal length of the atrial chamber, by causing the obstruction to the left ventricular (LV) filling, in the absence of additional pathologic findings. By considering that the atrial fibrillation had begun more than 48 h before and the need of investigating the above findings, we have decided to perform a transesophageal echocardiogram (TEE) the following day.\nThe TEE documented the presence of atrial thrombosis in the appendage, a spherical image with clear margins and fibrin branches inside, and a seamless cleavage with the posterolateral wall of the LA, which determined an obstacle to the ventricular filling [].\nWe decided to perform an urgent contrast-enhanced cardiac computed tomography (CT) which confirmed a capsulated lesion within the posterolateral left atrial wall with sharp margins and a basal density of + 30 HU, without any significant contrast enhancement in the arterial and late phases, features resembling those of a chronic hematoma [].\nAfter a consultation with our cardiac surgeon, and suspecting an atrial dissection, we planned to perform a cardiac magnetic resonance (CMR). CMR was performed with a 1.5T scanner with cine B-TFE, black-blood turbo spin echo, phase-sensitive inversion recovery, and THRIVE sequences before and after a standard 0.2 mmol/kg gadolinium contrast agent dose. CMR confirmed the intramural formation, within the inferolateral wall of the LA, with diameters of 4.3 cm × 6.2 cm × 4.4 cm, characterized by marked hyperintensity in T2-weighted sequences and high signal in both unsuppressed and fat-suppressed T1-weighted images, as well as the absence of signs of local invasiveness; a thin hypointense rim demarcated the lesion in the steady-state cine sequences. In contrast-enhanced images, a thin rim of peripheral enhancement is appreciated, mostly evident on the posterior side. These findings were deemed compatible with the original hypothesis of an intramural hematoma of the wall of the atrium, probably subacute/chronic [].\nIn consideration of the extension of the intramural hematoma and the LV inflow tract obstruction, the patient underwent a surgery to empty the hematoma and reattach the atrial wall.\nHistological examination confirmed the presence of histiocytes, crenated red blood cells, and crystals, hence a chronic hematoma [].
A 54-year-old female, a known case of rheumatic heart disease with severe mitral stenosis, MV area was 0.9 cm2, and moderate mitral regurgitation, was admitted to our hospital. The MV and subvalvular apparatus were calcified and there was moderate pulmonary arterial hypertension. Bilateral ventricular functions were within normal limits. She was posted for MV replacement (MVR) and informed consent was obtained. Her preoperative hematological investigations were within normal limits. General anesthesia was induced with standard medications and cardiopulmonary bypass (CPB) was established.\nShe underwent MVR with bioprosthetic valve 25 mm (EPIC, St. Jude Medical). Immediate post-CPB TEE showed normal functioning prosthetic valve and Doppler also revealed normal pressure gradients across the valve []. Her intraoperative period was uneventful and shifted to postoperative Intensive Care Unit (ICU) with minimal doses of inotropes. Postoperative day (POD) 0 was uneventful; however, on POD 1, she developed hypotension (arterial pressure 84/50 mmHg) that required increasing doses of inotropic support. Her central venous pressure was 20 mmHg and pulmonary artery pressure was 60/38 mmHg. Arterial blood gases also revealed metabolic acidosis. Due to her hemodynamic status, she could not be weaned off the mechanical ventilation.\nTEE was done to rule out cardiac tamponade and to evaluate the prosthetic MV function. It revealed a large cavitatory mass occupying the whole of left atrium (LA) which was obliterating the movement of MV leaflets [ and ]. Continuous wave Doppler (CWD) showed pressure gradient (peak/mean) of 19/10 mmHg across MV []. However, bilateral ventricular functions were within normal limits.\nOwing to her deteriorating hemodynamic condition, she was immediately shifted to the operating room. Chest was reopened and CPB was established. Opening of LA revealed dissection of the LA wall extending from the posterior annulus of the MV to the roof of LA. Clots were removed from the LA; however, the cavity again filled up. Therefore, it was decided to do the “marsupialization” for clearing of the cavity [ and ]. The bioprosthetic valve was also examined and was found to be normal. CWD also revealed normal gradient across prosthetic MV []. The patient was weaned off the CPB with low dose of inotropes. She was mechanically ventilated for 24 h and inotropes were gradually weaned off. She had longer stay in the ICU; otherwise her postoperative period was uneventful.