Case report
Intramural coronary hematoma, a complex three-dimensional entity: Multimodality assessment
Hematoma coronário intramural, uma realidade tridimensional complexa: avaliação multimodal
Iván J. Núñez-Gil
, Mauro Echavarría-Pinto, Gisela Feltes, Antonio Fernández-Ortiz*
Corresponding author
Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
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Núñez-Gil, Mauro Echavarría-Pinto, Gisela Feltes, Antonio Fernández-Ortiz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Iván J." "apellidos" => "Núñez-Gil" "email" => array:1 [ 0 => "ibnsky@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Mauro" "apellidos" => "Echavarría-Pinto" ] 2 => array:2 [ "nombre" => "Gisela" "apellidos" => "Feltes" ] 3 => array:3 [ "nombre" => "Antonio" "apellidos" => "Fernández-Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Hematoma coronário intramural, uma realidade tridimensional complexa: avaliação multimodal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3507 "Ancho" => 2501 "Tamanyo" => 968170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(A-C) Coronary angiograms, cranial view: (A) at presentation, the flow is clearly diminished (TIMI 1-2); (B) after implantation of the first stent; (C) final angiographic result; (D and E) IVUS and OCT, respectively, of the mid segment of the left anterior descending artery. White arrows indicate the intimal flap; (F and G) IVUS and OCT, respectively, after stent implantation, showing correct expansion and apposition; (H and I) IVUS and OCT, respectively, displaying the hematoma at the origin of a patent septal branch (star); (J) three-dimensional (3-D) OCT reconstruction at the same level as (I); (K) 3-D reconstruction after implantation of the first stent. The cross shows the hematoma and the luminal compromise; (L and M) final 3-D result. IVUS: intravascular ultrasound; OCT: optical coherence tomography.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 62-year-old woman was admitted with chest pain of two hours’ duration. Her medical history consisted only of dyslipidemia. The ECG presented changes (slight ST depression together with negative T waves) in the precordial leads, and the echocardiogram showed extensive and severe left ventricular anterolateral-apical hypokinesia (left ventricular ejection fraction 30%). Emergent catheterization was ordered, which showed severe left coronary flow disturbance (TIMI 1-2 flow) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A; <a class="elsevierStyleCrossRef" href="#sec0040">Video 1</a>). An intra-aortic balloon pump (IABP) and a drug-eluting stent (DES) were implanted in the mid-distal left anterior descending artery (LAD) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B). However, the flow disturbance persisted, with an apparent proximal stenosis on angiography. Optical coherence tomography (OCT) revealed diminished luminal area between the stent and the left main. Subsequent intravascular ultrasound (IVUS) provided a better view of the wall, showing an intracoronary hematoma (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D and E; <a class="elsevierStyleCrossRef" href="#sec0040">Video 5</a>), helping to establish the mechanism behind this situation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Spontaneous coronary dissection with intramural hematoma is a life-threatening condition of uncertain etiology and management. Conservative management is usually a good option if flow is preserved.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> Since our patient remained unstable, and suffered a propagation of the dissection, we decided to treat the remaining LAD/left main with two more DES, which was successful (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C, F, G and L; <a class="elsevierStyleCrossRef" href="#sec0040">Videos 2 and 4</a>). The patient progressed well and was successfully weaned from the IABP and discharged three days later. Peak troponin was 40 ng/dl (normal <0.05).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">It is sometimes difficult to establish a definitive diagnosis by angiography only. The superior qualities of intracoronary imaging (IVUS and OCT) can help provide the correct diagnosis and guide management. In this critical patient, multimodality intracoronary imaging provided crucial data on the mechanism responsible and helped to optimize treatment. This case depicts a complex patient, with an uncommon condition (propagation of a dissection/hematoma). It also enables a direct comparison between the capabilities of OCT and IVUS, and indicates that IVUS, which has lower definition but deeper penetration, can have a key role in intracoronary diagnosis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres831949" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec827784" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres831950" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec827785" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "Reference" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-13" "fechaAceptado" => "2016-05-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec827784" "palabras" => array:5 [ 0 => "Acute coronary syndrome" 1 => "Coronary dissection" 2 => "Optical coherence tomography" 3 => "Three-dimensional optical coherence tomography" 4 => "Intravascular ultrasound" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec827785" "palabras" => array:5 [ 0 => "Síndrome coronária aguda" 1 => "Disseção coronária" 2 => "Tomografia de coerência ótica" 3 => "Tomografia de coerência ótica 3-D" 4 => "Ultrassonografia intravascular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 62-year-old woman was admitted with chest pain of two hours’ duration, ECG changes in the precordial leads and left ventricular ejection fraction of 30% on the echocardiogram. Emergent catheterization demonstrated severe flow disturbance in the left coronary artery. An intra-aortic balloon pump and a drug-eluting stent were implanted. However, the flow disturbance persisted. Optical coherence tomography followed by intravascular ultrasound provided crucial data on the mechanism and helped to optimize treatment in this critical patient.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Uma mulher de 62 anos foi internada devido a dor torácica com duas horas de duração, associada a alterações eletrocardiográficas nas derivações precordiais e FEVE: 30% determinada por ecocardiografia. Um cateterismo emergente revelou alterações graves no fluxo da coronária esquerda. Foram implantados um balão intra-aórtico e um <span class="elsevierStyleItalic">stent</span> revestido. Contudo, o fluxo continuou com alterações. A tomografia de coerência ótica e a ultrassonografia intravascular proporcionaram os dados únicos acerca do mecanismo envolvido e contribuíram para otimizar o tratamento numa doente crítica.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0045" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3507 "Ancho" => 2501 "Tamanyo" => 968170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(A-C) Coronary angiograms, cranial view: (A) at presentation, the flow is clearly diminished (TIMI 1-2); (B) after implantation of the first stent; (C) final angiographic result; (D and E) IVUS and OCT, respectively, of the mid segment of the left anterior descending artery. White arrows indicate the intimal flap; (F and G) IVUS and OCT, respectively, after stent implantation, showing correct expansion and apposition; (H and I) IVUS and OCT, respectively, displaying the hematoma at the origin of a patent septal branch (star); (J) three-dimensional (3-D) OCT reconstruction at the same level as (I); (K) 3-D reconstruction after implantation of the first stent. The cross shows the hematoma and the luminal compromise; (L and M) final 3-D result. IVUS: intravascular ultrasound; OCT: optical coherence tomography.</p>" ] ] 1 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Video 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 855448 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Initial left anterior descending artery angiogram.</p>" ] ] 2 => array:7 [ "identificador" => "upi0010" "etiqueta" => "Video 2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1816619 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Final angiographic result.</p>" ] ] 3 => array:7 [ "identificador" => "upi0015" "etiqueta" => "Video 3" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 2720472 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional optical coherence tomography rendering after implantation of the distal stent. The intraluminal compromise and the septal anchoring is shown.</p>" ] ] 4 => array:7 [ "identificador" => "upi0020" "etiqueta" => "Video 4" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mp4" "ficheroTamanyo" => 3100454 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" ] "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional optical coherence tomography rendering showing the final result.</p>" ] ] 5 => array:7 [ "identificador" => "upi0025" "etiqueta" => "Video 5" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc5.mp4" "ficheroTamanyo" => 20730329 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc5.m4v" "poster" => "mmc5.jpg" ] "flv" => array:5 [ "fichero" => "mmc5.flv" "poster" => "mmc5.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Intravascular ultrasound pullback displaying evidence for the diagnosis, after the first stent.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Reference" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:1 [ 0 => array:3 [ "identificador" => "bib0010" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolutive recanalization of spontaneous coronary artery dissection: insights from a multimodality imaging approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B.C. Das Neves" 1 => "I.J. Núñez-Gil" 2 => "F. Alfonso" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.112.000101" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2014" "volumen" => "129" "paginaInicial" => "719" "paginaFinal" => "720" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24515959" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003600000004/v1_201704230025/S2174204917300946/v1_201704230025/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003600000004/v1_201704230025/S2174204917300946/v1_201704230025/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300946?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 5 | 11 |
| 2024 October | 43 | 29 | 72 |
| 2024 September | 50 | 20 | 70 |
| 2024 August | 37 | 28 | 65 |
| 2024 July | 36 | 26 | 62 |
| 2024 June | 28 | 20 | 48 |
| 2024 May | 36 | 29 | 65 |
| 2024 April | 32 | 20 | 52 |
| 2024 March | 37 | 27 | 64 |
| 2024 February | 23 | 44 | 67 |
| 2024 January | 21 | 39 | 60 |
| 2023 December | 23 | 26 | 49 |
| 2023 November | 21 | 20 | 41 |
| 2023 October | 24 | 20 | 44 |
| 2023 September | 24 | 22 | 46 |
| 2023 August | 29 | 20 | 49 |
| 2023 July | 24 | 12 | 36 |
| 2023 June | 28 | 12 | 40 |
| 2023 May | 28 | 18 | 46 |
| 2023 April | 23 | 4 | 27 |
| 2023 March | 33 | 21 | 54 |
| 2023 February | 24 | 19 | 43 |
| 2023 January | 18 | 9 | 27 |
| 2022 December | 22 | 19 | 41 |
| 2022 November | 24 | 20 | 44 |
| 2022 October | 25 | 13 | 38 |
| 2022 September | 21 | 27 | 48 |
| 2022 August | 20 | 29 | 49 |
| 2022 July | 24 | 35 | 59 |
| 2022 June | 20 | 20 | 40 |
| 2022 May | 22 | 37 | 59 |
| 2022 April | 21 | 32 | 53 |
| 2022 March | 25 | 44 | 69 |
| 2022 February | 32 | 40 | 72 |
| 2022 January | 34 | 24 | 58 |
| 2021 December | 22 | 33 | 55 |
| 2021 November | 28 | 41 | 69 |
| 2021 October | 37 | 41 | 78 |
| 2021 September | 31 | 21 | 52 |
| 2021 August | 32 | 35 | 67 |
| 2021 July | 12 | 18 | 30 |
| 2021 June | 27 | 22 | 49 |
| 2021 May | 32 | 37 | 69 |
| 2021 April | 42 | 31 | 73 |
| 2021 March | 58 | 29 | 87 |
| 2021 February | 47 | 17 | 64 |
| 2021 January | 25 | 12 | 37 |
| 2020 December | 42 | 11 | 53 |
| 2020 November | 32 | 14 | 46 |
| 2020 October | 19 | 15 | 34 |
| 2020 September | 66 | 11 | 77 |
| 2020 August | 19 | 8 | 27 |
| 2020 July | 42 | 12 | 54 |
| 2020 June | 47 | 7 | 54 |
| 2020 May | 44 | 3 | 47 |
| 2020 April | 35 | 13 | 48 |
| 2020 March | 39 | 8 | 47 |
| 2020 February | 85 | 15 | 100 |
| 2020 January | 36 | 9 | 45 |
| 2019 December | 49 | 3 | 52 |
| 2019 November | 28 | 6 | 34 |
| 2019 October | 38 | 4 | 42 |
| 2019 September | 35 | 10 | 45 |
| 2019 August | 34 | 8 | 42 |
| 2019 July | 43 | 12 | 55 |
| 2019 June | 18 | 16 | 34 |
| 2019 May | 46 | 9 | 55 |
| 2019 April | 31 | 17 | 48 |
| 2019 March | 128 | 6 | 134 |
| 2019 February | 106 | 7 | 113 |
| 2019 January | 105 | 6 | 111 |
| 2018 December | 107 | 11 | 118 |
| 2018 November | 122 | 14 | 136 |
| 2018 October | 168 | 12 | 180 |
| 2018 September | 52 | 10 | 62 |
| 2018 August | 39 | 4 | 43 |
| 2018 July | 36 | 1 | 37 |
| 2018 June | 47 | 4 | 51 |
| 2018 May | 40 | 4 | 44 |
| 2018 April | 65 | 8 | 73 |
| 2018 March | 46 | 10 | 56 |
| 2018 February | 39 | 6 | 45 |
| 2018 January | 36 | 7 | 43 |
| 2017 December | 37 | 12 | 49 |
| 2017 November | 19 | 12 | 31 |
| 2017 October | 22 | 7 | 29 |
| 2017 September | 19 | 6 | 25 |
| 2017 August | 25 | 10 | 35 |
| 2017 July | 21 | 7 | 28 |
| 2017 June | 29 | 10 | 39 |
| 2017 May | 52 | 24 | 76 |
| 2017 April | 9 | 6 | 15 |
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