PMC5478569_01
A series of follow-up transthoracic echocardiographic images of an intramyocardial dissecting hematoma (white arrows) in a four-chamber view. (A) On admission. (B) At Day 3, because of the enlargement of the hematoma, antithrombotic agents were discontinued. (C and D) At Day 9 and 15, gradual remission of the hematoma was seen. (E) At Day 23 (before coronary artery bypass grafting surgery), the hematoma had disappeared. (F) One month after coronary artery bypass grafting, no recurrence of the hematoma was seen.
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The four-chamber view demonstrated a pulsatile mass with heterogenic echogenicity at the infarcted apical-septal region (Fig. 1A, Movie S1). However, an echocardiogram on day 3 after admission showed apical mass enlargement with considerable movement, and the uninterrupted endocardium appeared to delineate the mass on the left ventricular cavity (Fig. 1B). Thereafter, the hematoma gradually shrank in size each day, and we finally confirmed its disappearance on Day 23 after admission (Fig. 1C-E). There was no recurrence of the hematoma even after the antiplatelet therapy was restarted (Fig. 1F, 2C-D).
Cardiac magnetic resonance views in a four-chamber orientation on Day 3 (A and B) and one month after coronary artery bypass grafting (CABG) (C and D) using T2-weighted imaging (left) and late-gadolinium enhancement (right). (A) The hematoma (asterisks) was surrounded by the non-ruptured endocardial flap as the inner layer and by the infarcted myocardium with high intensity at the apical-septal lesion as the outer layer. (B) The infarcted myocardium was brightly enhanced, and the enhancement was also seen on the side of the inner layer (white arrow). (C and D) There were no findings indicative of recurrence of the hematoma.
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T1 and T2 images at the apex were consistent with a relatively new and unorganized hematoma. T2-weighted images demonstrated an endocardial layer and an infarcted myocardium, which delineated the hematoma between the left ventricular cavity and epicardial border (Fig. 2A). Furthermore, late gadolinium-enhanced MRI using phase-sensitive inversion recovery revealed the enhanced myocardium on the side of not only the epicardium but also the endocardium (Fig. 2B). There was no recurrence of the hematoma even after the antiplatelet therapy was restarted (Fig. 1F, 2C-D).