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Interventricular septum hematoma during cineventriculography
© Grohmann et al; licensee BioMed Central Ltd. 2008
Received: 27 August 2007
Accepted: 16 January 2008
Published: 16 January 2008
Intraseptal hematoma and subsequent myocardial infarction due to accidental contrast agent deposition complicating diagnostic cineventriculography is a previously undescribed complication of angiography.
A 61 year old man was admitted at intensive care unit because of unstable angina pectoris 1 hour after coronary angiography. Transthoracic contrast echocardiography showed a non-perfused area in the middle of interventricular septum with an increase of thickening up to 26 mm. Review of cineventriculography revealed contrast enhancement in the interventricular septum after contrast medium injection and a dislocation of the pigtail catheter tip. Follow up by echocardiography and MRI showed, that intramural hematoma has resolved after 6 weeks. After 8 weeks successful stent implantation in LAD was performed and after 6 month the patient had a normal LV-function without ischemic signs or septal thickening demonstrated by stressechocardiography.
A safe and mobile position of the pigtail catheter during ventriculography in the middle of the LV cavity should be ensured to avoid this potentially life-threatening complication. For assessment and absolute measurement of intramural hematoma contrast-enhanced echocardiography is more feasible than MRI and makes interchangeable results.
This case illustrates the first description of an accidental contrast agent deposition into the interventricular septum complicating cineventriculography in a patient with suspected coronary artery disease. Intramural hematoma developed subsequently-leading to myocardial infarction.
A 61 year old patient with sudden onset of typical angina pectoris, sweat and a sinus bradycardia of 40 beats per minute was admitted at intensive care unit. It was known, that he had an elective coronary angiography at the same day because of suspected coronary artery disease with typical chest pain and exercise induced dyspnoea as well as paroxysmal atrial fibrillation. His baseline treatment was for arterial hypertension metoprolol (150 mg/d) and ramipril (2,5 mg/d), for atrial fibrillation dalteparin (3 × 5.000 IU/d) and for expected angioplasty aspirin (100 mg/d) and loading dose of clopidogrel (300 mg at the first day). The coronary angiography report described a severe proximal type B2 stenosis and a medial type B stenosis of the left anterior descending artery (LAD). Intended angioplasty of the LAD and implantation of a special stent was planned for the next day.
CK max value of 1082 U/l and Troponin I I value of 80 ng/ml were observed during the same day. The following day ECG showed ST-segment elevation in V1 (+0.15 mV) and V2 (+0.25 mV) indicating myocardial infarction. No ventricular arrhythmias or atrio-ventricular block caused by the septal infarction were observed. 2 days after contrast agent deposition into interventricular septum CK values decreased dewithin normal range. 2 weeks later, transthoracic echocardiography revealed a maximum of septum thickness with 28 mm, a non-perfused area of 2.6 × 4.7 cm with a strain of -4% and a strain rate of 0,45/s as well as an akinesia in the middle septum.
Discussion and conclusion
Intramyocardial hemorrhage is a rare but known complication of myocardial infarction, percutaneous coronary artery intervention or angiography [1–7]. Intraseptal hematoma after ventricular septal defect closure is described in infants and requires surgically treatment [8, 9]. An interventricular septum hematoma and myocardial infarction due to accidental contrast agent deposition complicating diagnostic cineventriculography is a previously undescribed complication of angiography. Intramural hematoma can be detected by contrast echocardiography  and magnetic resonance imaging . Our findings confirm interchangeable results of contrast echocardiography and MRI regarding to absolute measurements and reproducibility . Furthermore, in our case the assessment of myocardial perfusion and scar by contrast echocardiography is as good as that of MRI.
The possible reason for this complication seems to be the in correct position of pigtail catheter followed by high pressure injection of contrast medium intramuraly. In addition complex strategy of antiplatelet- and anti Xa-medication may have forwarded rupture of vasa vasorum.
In conclusion, a safe and mobile position of the pigtail catheter during ventriculography in the middle of the LV cavity should be ensured to avoid this potentially life-threatening complication. For assessment and measurement of intramural hematoma contrast-enhanced echocardiography is more feasible than MRI and makes interchangeable results.
The authors gratefully thank Christine Scholz for excellent technical assistance. Written informed consent for publication was obtained from the patient.
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