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Ann Thorac Surg 2008;86:e9. doi:10.1016/j.athoracsur.2008.09.062
© 2008 The Society of Thoracic Surgeons
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Images in Cardiothoracic Surgery

Subepicardial Hematoma Compressing the Right Atrium: Spontaneous Rupture of the Right Coronary Artery

Kyung Hwa Kim, MD, Jong Bum Choi, MD*, Kong Su Kim, MD

Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Hospital, Jeonju, Republic of Korea

* Address correspondence to Dr Choi, Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, 634-18 Geumam-dong, Jeonju, Chonbuk, 561-712, Republic of Korea (Email: jobchoi{at}cuh.co.kr).

A 28-year-old man, diagnosed 3 years ago with Behçet disease, presented with inspiratory compressing chest pain and shortness of breath. Echocardiography showed a 5.9-cm diameter pericardial mass compressing the right atrium (RA) and the tricuspid valve (Fig 1A, white arrow). The decreased valve area increased maximum flow velocity to 2.2 m/s, and the inferior vena cava was dilated to 27-mm diameter with plethora. A chest computed tomography scan showed a 6.0-cm cystic, rounded mass compressing the RA and atrioventricular groove. Extravasation suggested it was a hematoma caused by rupture of the right coronary artery (CA; Fig 1B, white arrow). Coronary angiography showed total occlusion of the right CA and extravasation from the proximal portion of the CA (Fig 1C, white arrow). Intervention for CA occlusion was not performed.


Figure 1
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  		Fig 1.
 
An operation was performed through a median sternotomy under cardiopulmonary bypass. Little blood was in the pericardial space. The RA epicardium was obliquely incised outside the RA myocardium. The hematoma, which was enveloped by the (Fig 1D; a) tricuspid valve annulus at the base, (Fig 1D; b) the external epicardium, (Fig 1D; c) and the internal myocardium of the right atrium (Fig 1D), was evacuated. Neither bleeding point nor injured CA was seen in the atrioventricular groove.

After removal of the hematoma, the epicardium and myocardium of the RA were approximated from the valve annulus to the epicardial incision using BioGlue (CryoLife Inc, Kennesaw, GA), with interrupted 4-0 polypropylene suture from the RA cavity to the epicardium through a small atriotomy. The right CA was not grafted because of difficult approach to the artery and good collateral circulation from the left CA.

The patient's postoperative course was uneventful, and he was discharged on postoperative day 10. The postoperative echocardiogram showed resumed volume to the RA and decreased flow velocity through the tricuspid vale (1.4 m/s) without plethora.

Spontaneous rupture of CA is a rare complication in patients with Behçet disease. Removal of the subepicardial hematoma on the RA and reattachment of the epicardial flap to the myocardium improved the flow disturbance in the right heart in our patient.





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