Images in Cardiovascular Medicine Coronary Embolization of an Intramyocardial Hematoma After Myocardial Infarction

62-year-old man with a history of smoking, hypertension,and hypercholesterolemia was admitted for an inferiorST-segment elevation myocardial infarction (Figure 1). Coro-nary angiography performed 1 hour after the onset of chest painrevealed that the posterolateral artery was aneurysmal andobstructed. This blockage was treated by percutaneous coronaryintervention with balloon angioplasty but without stent implanta-tion. At the end of the procedure, a small area of contrast agentstagnationwasfoundinthepericardialarea.Chestx-rayrevealednoevidence of pleural effusion or pulmonary edema (Figure 2).Transthoracic echocardiography (TTE) (ViVid 7; GE Health-care, Chalfont St. Giles, UK) showed inferior wall hypokinesiswith a preserved left ventricular ejection fraction of 50%. Wealso found a large septal mass and a small pericardial effusion.AsshowninFigure3,thismassexpandedintotherightventricleandhadahighechodensity.AmyocardialcontrastTTErevealedcomplete enhancement of the mass (Figure 4), suggesting amyocardial mass instead of a thrombus.Cardiac computed tomography (GE Healthcare) with aniodinated contrast agent ruled out the presence of a tumor.However, we discovered a large myocardial hematoma of theinferior interventricular septum, measuring 41 38 70 mm,with active bleeding (Figure 5 and online-only Data SupplementMovie I) from the posterior descending artery. These findingssuggested a septal hematoma caused by perforation of theposterior descending artery during the initial percutaneous cor-onary intervention. Given the risks of hematoma progression orseptal rupture, we performed a second coronary angiography toattempt a percutaneous hemostatic procedure. Direct injectionintotherightcoronaryarteryconfirmedextravasationofcontrastagent from the posterior descending artery, which suggestedactive bleeding from this coronary artery (Figure 6A). Becausethe extravasation disappeared after balloon inflation of theposterior descending artery, the feeding artery was embolizedusing 3 steel coils. Contrast agent stagnation disappeared com-pletely after coil embolization (Figure 6B).A repeat-contrast TTE performed 1 day later showed noenhancement of the myocardial hematoma (Figure 7). Thepatient underwent magnetic resonance imaging 10 days later(clinical 3-T ACHIEVA; Philips Medical Systems, Eindhoven,the Netherlands). Four-chamber imaging showed an abnormalsignal area in the right side of the interventricular septum,sparing the subendocardium (Figure 8 and online-only DataSupplementMovieII).Thishigh-signalareawaslocalizedtotheinferior interventricular septum on short-axis views. The patientwas discharged from the hospital on a regimen of antiplateletagents (aspirin and clopidogrel), a -adrenergic blocker, anangiotensin-converting enzyme inhibitor, and a statin.The 3-month postembolization follow-up TTE revealed animpressive regression of the intramyocardial hematoma (Figure9) with only a slight myocardial mass on the basal interventric-ular septum. Cardiac magnetic resonance imaging confirmedthatthehematomahadregressedastheoriginalareaofabnormalsignaling had disappeared (Figure 10). Six months after theprocedure, the patient remained free from cardiovascular events.Intramyocardial hematoma is a subacute, partial rupture of themyocardium. These hematomas usually occur after myocardialinfarction, chest trauma, surgery, or percutaneous coronary inter-vention,buttheycanalsodevelopspontaneously.