PMC5367147_01
Coronary angiogram (A) RAO view of native coronary vessels. The OM2
shows a long-segment discontinuity (black arrow) around the bypass anastomosis.
(B) RAO view of the LIMA-OM2 bypass: from the anastomosis, there is retrograde
flow into the OM2, TIMI 2 flow into the distal OM2, and a large spherical space is
contrast enhanced. (C) LAO view of the LIMA-OM2 bypass anastomosis shows an
apparent leak of contrast medium at the region of the anastomosis into a paraventricular
spherical space (white arrow). LAO, left anterior oblique; LIMA, left internal mammary
artery; OM2, obtuse marginal branch 2; RAO, right anterior oblique.
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The reduced coronary flow in OM2 was attributed to impaired inflow due to anastomosis leakage (Fig. 1).
Multiplanar reconstruction of the cardiac CT (ECG-triggered mid-diastolic
recording). (A) Two-chamber view of the left ventricle and the left atrium.
(B) Four-chamber view. (C) Short-axis view. Imaging shows a spherical
space (white arrows) adjacent to the basal lateral wall of the left ventricle (diameter
5.5 x 3.1 x 5.0 cm). There is slight contrast medium enhancement in this space. The
space can be anatomically localized outside the myocardium and appears not to be
connected to the pericardium (asterisks), thus being bordered by the epicardium. CT,
computed tomography; ECG, electrocardiogram.
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The hematoma appeared to localize subepicardially and not intrapericardially (Fig. 2).
Surgical removal of the subepicardial hematoma and repair of the LIMA-OM2
bypass anastomosis. View into the operation site from caudal-anterior perspective
(course of the bypass in (c):(e): white asterisks). (A) The patient
is on cardiopulmonary bypass and the heart elevated to the right. The exposed hematoma
on the left lateral wall is located subepicardially without connection to the
pericardial space. (B) After opening the epicardial cover of the hematoma, a
partially organized clot is removed. (C) Exposure of the anastomosis: a small
defect with pulsating bleeding is identified. (D) The defect is repaired with a
single suture. (E) To further secure the site of anastomosis, a hemostatic patch
(Veriset) is applied. (F) Removed hematoma mass. LIMA, left internal mammary
artery; OM2, obtuse marginal branch 2.
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The subepicardial hematoma was observed to be without connection to the pericardial space (Fig. 3A) at the lateral cardiac wall. After evacuation of the hematoma, bleeding from a small anastomosis suture leak was identified and closed with a single suture by adapting the adventitial tissue (Prolene 8/0) (Fig. 3C, D). As we observed some diffuse bleeding from the preparation region around the anastomosis, a hemostatic patch (Veriset) was applied (Fig. 3E).
Coronary angiogram on POD 4. (A) The native left circumflex artery
shows the previously known stenosis of OM2. The OM2 distal to the bypass anastomosis
shows no narrowing. (B) The LIMA-OM2 bypass shows good function without leakage
of contrast medium and TIMI 3 flow in the distal OM2. LIMA, left internal mammary
artery; OM2, obtuse marginal branch 2; POD, postoperative day; TIMI, thrombolysis in
myocardial infarction classification.
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OM2 (Fig. 4). On POD 7, a pericardial effusion (400 mL; exudative, hemoglobin 1.3 g/dL) was removed by ultrasound-guided pericardiocentesis and immunosuppressive therapy with prednisolone and ibuprofen for postcardiotomy syndrome was initiated.