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 69-year-old man was admitted in our hospital due to fever, chill, orthopnea and paroxysmal nocturnal dyspnea. In physical examination, respiratory sounds were reduced in both his lower half of lung fields.\nHe had undergone a major cardiac surgery including CABG, MVR, aortic valve replacement (AVR) and ascending aorta replacement due to severe coronary artery disease, significant valvular heart disease (rheumatic) and aneurysmally dilated ascending aorta, 75 days prior to his recent admission.\nAn electrocardiogram revealed atrial fibrillation rhythm, normal axis and non-specific ST-T changes in inferior and lateral leads (). The posteroanterior view of the chest radiography showed massive bilateral pleural effusion. Transthoracic echocardiography followed by TEE showed normal LV size with preserved systolic function, bioprosthetic MV with acceptable hemodynamic and mobility and no paravalvular regurgitation. Bioprosthetic AV had acceptable hemodynamic and mobility without paravalvular regurgitation. There was normal functioning ascending aorta Dacron tube graft without leakage from proximal and distal part of prosthesis.\nThe LA was enlarged and dissection was found on the posterior wall. Two homogenous particles (1.18 × 0.4 cm and 0.9 × 0.58 cm) were attached to the dissecting flaps which were highly suggestive for vegetations and IE (, , and , , , and ).\nLaboratory tests showed severe coagulopathy, high levels of fibrin degradation products, leukocytosis (white blood cells count: 26700/cm3, predominantly poly morphonucleated), severe anemia, thrombocytopenia, elevated liver enzymes and serum creatinine levels. These data were suggestive for DIC. The blood culture revealed enterococci septicemia.\nHis general condition deteriorated rapidly. He suffered from tonic-clonic seizures, diminished consciousness, widespread mucosal bleeding and oliguria. Bilateral chest tubes were inserted for massive pleural effusion. The patient was treated with intravenous vancomycin, cefepim, gentamycin and oral rifampin. He received infusion of fresh frozen plasma, packed cells, valproic acid, diazepam and phenytoin.\nBased on his poor general condition, cardiac surgery was not performed and finally he expired from multi organ failure. Autopsy findings were consistent with clinical, laboratory and echocardiographic findings.