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 55-year-old man presented with rheumatic heart disease, severe mitral regurgitation, moderate pulmonary arterial hypertension, and good biventricular function. He was scheduled for mitral valve replacement (MVR). After applying standard monitors and preoxygenation, general anesthesia was induced with 2 mg of midazolam, 50 mg of propofol, 200 μg of fentanyl, 60 mg of lidocaine, and 8 mg of vecuronium. Anesthesia was maintained with oxygen: Air, 1% isoflurane, and intermittent doses of fentanyl. The trachea was intubated with an 8.5-mm single-lumen tracheal tube. A right femoral arterial catheter was placed for continuous blood pressure monitoring.\nMVR with 29 mm St. Jude mechanical prosthetic valve with posterior mitral leaflet preservation was performed through transseptal approach on conventional cardiopulmonary bypass (CPB) and cold blood cardioplegia. The patient was weaned off CPB with the optimal inotropic support of 5 μg/kg/min of dopamine and 5 μg/kg/min dobutamine. But, the pressures were on borderline around 80/38 mmHg, and right ventricle appears to be distending with poor myocardial contractions. So, we decided to put transesophageal echocardiography (TEE) probe to see for any abnormality. To our surprise, we saw a circular hypoechoic mass in the left atrial (LA) free wall encroaching onto the mitral valve []. This finding was discussed with the surgeon, who decided to re-explore the LA. LA atriotomy was reopened, the mitral valve appeared to be well seated, and there was no evidence of dissection. Only the LA free wall appeared to have subendocardial blood collection. There were no continuities between the cavity and the LA, left ventricle, posterior pericardial space. Marsupialization of the cavity is done and opened it to the LA cavity [].\nThe patient was then weaned from CPB for the 2nd time with inotropic support of 0.375 μg/kg/min of milrinone, 5 μg/kg/min of dopamine, 5 μg/kg/min dobutamine, and 0.05 μg/kg/min of nor epinephrine. The post-bypass TEE examination showed that LA dissection (LAd) wall appeared to be incised in the middle and drained out the blood.\nThe patient's postoperative course was complicated by intermittent periods of desaturation which required bi-level airway pressure ventilation with which he showed improvement in oxygenation. The patient was discharged from the hospital 15 days after surgery.