ELECTRONIC PAPERS
European Journal of Echocardiography (2010) 11, E18 doi:10.1093/ejechocard/jep210
Left atrial intramural haematoma associated with mitral annular calcification Francisco Gual-Capllonch 1*, Javier Arce 2, Luis Sere´s1, Nuria Vallejo 1, Elena Ferrer1, Claudio Ferna´ndez 3, Jorge Lo´pez-Ayerbe 1, and Albert Teis 1 1 Department of Cardiology, Hospital Germans Trias i Pujol, Carretera Canyet, s/n, Barcelona 08916, Spain; 2Cardiac Magnetic Unit-IDI, Hospital Germans Trias i Pujol, Badalona, Spain; and 3Department of Cardiac Surgery, Hospital Germans Trias i Pujol, Badalona, Spain
Received 18 September 2009; accepted after revision 17 November 2009; online publish-ahead-of-print 11 December 2009
Left atrial wall haematoma is a very uncommon entity, associated mainly to cardiac surgery, interventional procedures, or trauma. Spontaneous cases are supposed to be associated with left atrial wall pathology. We present a case of a 53-year-old male who was admitted for prolonged chest pain, with transthoracic and transesophagic echocardiography documentation of a left atrial mass in close proximity to a mitral annular calcification. Tissue characterization with cardiac magnetic resonance suggested the aetiology of the mass, which was confirmed histologically.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Left atrial mass † Intramural haematoma † Mitral annular calcification † Cardiac magnetic resonance
Case report A 53-year-old man was admitted to our institution with prolonged chest pain. His past medical history comprised hypercholesterolaemia, obstructive sleep apnoea syndrome, and some episodes of atypical chest pain 3 years ago. At the time, an echocardiogram showed normal regional and global left ventricular performance and mitral annular calcification as the only pathological finding, and an exercise testing was normal. He had been asymptomatic for the last 3 years. The chest pain had begun 2 days before, was squeezing, and did not radiate. There were no other symptoms associated. At the time of admission, his haemodynamic status remained stable, with low-grade fever (37.68C), and the cardiovascular examination was completely normal. The electrocardiogram, thorax X-ray, and laboratory test were also unremarkable, except for a minor troponin I increase (0.8 U/L, normal below 0.5 U/L). A transthoracic echocardiogram (Figure 1 and Supplementary data online, Video S1) showed mild left ventricular hypertrophy, normal ejection fraction, no wall-motion abnormalities, severe mitral annulus calcification, and a cystic mass (size 32 46 mm) located in the posterolateral wall of the left atrium (LA), which did not produce blood flow obstruction and did not enhance with intravenous contrast (Sonovuew) (Supplementary data online, Video S2). In the transesophageal echocardiogram (Figure 2), the mass appeared to be capsulated, with inhomogeneous content and did not hamper the pulmonary veins flow. A cardiac magnetic resonance revealed a well-defined oval mass located in the
posterolateral left atrial wall (Figure 3), homogeneous and markedly hyperintense on T1-weighted images and isointense on T2-weighted images. In fat-saturated images, the signal persisted hyperintense (Figure 4) and did not show increased contrast uptake. These findings suggested that the mass content consisted of encapsulated blood inside the left atrial wall. A coronary angiography showed normal coronary arteries and mitral annulus calcification. Cardiac surgery was performed with institution of cardiopulmonary bypass. A mass was found bulging into the LA cavity, with intact endocardium. After its incision, a brownish material was aspirated, and the atrial wall was sewn. The histopathological examination of the specimen showed mainly erythrocytes, fibrin, and scattered leucocytes, so that diagnosis of intramural haematoma of the left atrial wall was established. The post-operative course was uneventful, and the predischarge and 6-month follow-up echocardiogram did not exhibit any residual mass or abnormalities except for mitral annular calcification and mild mitral regurgitation.
Discussion Intramural haematoma is a very uncommon cause of left atrial mass. It has been described as a rare complication after mitral valve surgery or mitral infective endocarditis, originated from a dissection of the atrial wall at the auriculoventricular annulus,1,2 after blunt chest trauma,3 myocardial infarction,4 and as a result of vascular fragility in cardiac amyloidosis.5 Other iatrogenically induced intramural left atrial haematomas are related to percutaneous
* Corresponding author. Tel: þ34 617 42 6037, Email:
[email protected]/
[email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email:
[email protected].
E18
The diagnosis of left atrial intramural haematoma
Figure 1 Transthoracic apical four-chambers view, demonstrating a cystic mass in the posterolateral left atrial wall (arrows).
Figure 3 Two chambers ECG-gated breath-hold SSFP image, showing LA mass.
Figure 2 Transesophageal echocardiogram, longitudinal view, showing inhomogeneous cystic mass (arrows).
coronary interventions or radiofrequency catheter ablations.6,7 In the absence of predisposing factors, the diagnosis of atrial intramural haematoma is even more difficult to uncover and differential diagnosis broadens.8,9 In the present case, the left atrial mass was in close proximity to a mitral annular calcification, which could be the origin of the dissection in the left atrial wall. To our knowledge, only one case of an intramural left atrial haematoma complicating mitral annular calcification has been previously reported.10 However, it differs from our patient as it was associated with an infected annular abscess adjacent to the mitral calcification. In our case, every imaging technique employed provided complementary information about the characteristics and possible aetiologies of the mass. The absence of contrast enhancement on transthoracic echocardiogram suggested lack of vascularization of the mass.11 Transesophageal echocardiography further delineated the content, location, and relationship with other structures, and coronary angiography confirmed the calcified nature of the mitral annulus. On the other hand, cardiac magnetic resonance provided valuable information regarding tissue
Figure 4 Cardiac magnetic resonance, T1-fat suppression pulse, demonstrating hyperintense signal, suggestive of haemosiderin content (arrow). characterization12 and anatomic location. All these distinctive features suggested the diagnosis of left atrial intramural haematoma, which was confirmed histologically.
Supplementary data Supplementary data are available at European Journal of Echocardiography online. Conflict of interest: none declared.
F. Gual-Capllonch et al.
References 1. Gallego P, Oliver JM, Gonza´lez A, Domı´nguez FJ, Sa´nchez-Recalde A, Mesa JM. Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition. J Am Soc Echocardiogr 2001;14:813–20. 2. Cordero ML, Lo´pez JM, Merayo E, Gulı´as JM, Paz J. Left atrial dissection and infective endocarditis. Rev Esp Cardiol 1998;51:402–3. 3. Rowe SK, Porter CB. Atrial septal hematoma: two-dimensional echocardiographic findings after blunt chest trauma. Am Heart J 1987;114:650–2. 4. Kovacic JC, Horton MD, Campbell TJ, Wilson SH. Left atrial hematoma complicating inferior myocardial infarction. J Am Soc Echocardiogr 2004;17:1201 –3. 5. Edibam C, Playford D, Texler M, Edwards M. Isolated left atrial amyloidosis: acute premitral stenosis secondary to spontaneous intramural left atrial hemorrhagic dissection. J Am Soc Echocardiogr 2006;19:938.e1 –e4. 6. Solzbach U, Beuter M, Haas H. Left atrial hematoma after percutaneous coronary intervention. Int J Cardiol 2009; [Epub ahead of print].
E18 7. Sah R, Epstein LM, Kwong RY. Intramural atrial hematoma after catheter ablation for atrial tachyarrhythmias. Circulation 2007;115:e446 –7. 8. Lombardo A, Luciani N, Rizzello V, Natale L, Pennestrı´ F, Ricci R et al. Spontaneous left atrial dissection and hematoma mimicking a cardiac tumor: findings from echocardiography, cardiac computed tomography, magnetic resonance and pathology. Circulation 2006;114:e249–50. 9. Lanfranchi A, Gelpi G, Rossi RS, Lemma M. A fast-growing obstructive left atrial intramural hematoma causing acute prolonged chest pain. Interact Cardiovasc Thorac Surg 2009;9:363–5. 10. Schecter SO, Fyfe B, Pou R, Goldman ME. Intramural left atrial hematoma complicating mitral annular calcification. Am Heart J 1996;132:455 –7. 11. Kirkpatrick JN, Wong T, Bednarz JE, Spencer KT, Sugeng L, Ward RP et al. Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging. J Am Coll Cardiol 2004;43:1412 –9. 12. Sparrow PJ, Kurian JB, Jones TR, Sivananthan MU. MR imaging of cardiac tumors. Radiographics 2005;25:1255 –76.
