\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[greek,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Left Atrial Intramural Hematoma after Percutaneous Coronary Intervention}



\author[1]{Jun Takaki}%
\author[1]{Takashi Yoshinaga}%
\author[1]{Kosaku Nishigawa}%
\author[1]{Ken Okamoto}%
\author[1]{Toshihiro Fukui}%
\affil[1]{Kumamoto University Hospital}%


\vspace{-1em}



  
  \date{May 22, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Left atrial intramural hematoma is a rare complication of percutaneous
coronary intervention. We report a case of left atrial intramural
hematoma after percutaneous coronary intervention that was successfully
treated by combining surgery with interventional therapy.%
\end{abstract}%



\sloppy


\textbf{Left Atrial Intramural Hematoma after Percutaneous Coronary
Intervention}

Running title: Left atrial intramural hematoma

Jun Takaki, MD, Takashi Yoshinaga, MD, Kosaku Nishigawa, MD, Ken
Okamoto, MD,

and Toshihiro Fukui, MD

Department of Cardiovascular Surgery, Kumamoto University Hospital

There is no source of funding.

Corresponding author: Toshihiro Fukui

Department of Cardiovascular Surgery

Kumamoto University Hospital

1-1-1 Honjo, Kumamoto 860-8556, Japan

Tel: +81-96-373-5202

Fax: +81-96-373-5207

Email: \emph{tfukui.cvs@gmail.com}

\textbf{Key clinical message}

Left atrial intramural hematoma is a rare complication of percutaneous
coronary intervention. The combination treatment with surgery and
interventional therapy is one of therapeutic options.

\textbf{Abstract}

Left atrial intramural hematoma is a rare complication of percutaneous
coronary intervention. We report a case of left atrial intramural
hematoma after percutaneous coronary intervention that was successfully
treated by combining surgery with interventional therapy.

\textbf{Key words}

Complications, PCI, surgery

\textbf{Introduction}

Left atrial intramural hematoma (LA IMH) as a complication of
percutaneous coronary intervention (PCI) is a very rare entity. We
herein report a case of LA IMH after PCI that were successfully treated
by combining surgery with interventional therapy.

\textbf{Case Report}

A 79-year-old man with a history of hypertension, diabetes, chronic
kidney disease, aplastic anemia, and thrombocytopenic purpura was
admitted to another hospital with severe chest pain. He was diagnosed
with unstable angina, and underwent immediate coronary angiography.
There was a 75\% stenosis in the right coronary artery (RCA), and 90\%
stenosis in the left anterior descending artery (LAD) and left
circumflex artery (LCX). PCI for LAD and LCX was successfully performed.

Ten hours after the PCI, the patient complained of severe dyspnea.
Echocardiogram revealed that a mass occupied the LA cavity (Figure 1).
The patient was transferred to our hospital for the treatment of left
atrial mass causing acute heart failure.

At presentation, he was hemodynamically stable on dobutamine of 1\selectlanguage{greek}γ\selectlanguage{english}and
oxygen (blood pressure 100/60 mmHg, pulse 90 beats/min, and saturation
95\%). Echocardiography showed that the mean pressure gradient through
the mitral valve was 8.3 mmHg and estimated systolic pulmonary arterial
pressure was 50 mmHg. Computed tomography (CT) showed a large mass (88
mm \selectlanguage{ngerman}× 60 mm) in the LA (Figure 2); however, no contrast effect was seen
in the mass. The patient was diagnosed with acute heart failure due to
the LA mass causing functional mitral stenosis (MS), and underwent
emergent surgery for mass removal.

Under median sternotomy, cardiopulmonary bypass was established with
ascending aortic and bicaval cannulations. After aortic clamping, the
incision of LA was made through the superior transseptal approach.
Inside the LA, tumor was not detected and the endocardium was intact.
However, a remarkable bulging of the entire posterior wall of the LA was
observed and the endocardium of the LA wall was incised. There was a
voluminous clot in the LA wall. After complete evacuation of the clot,
the endocardium of the posterior wall was sewn with 5-0 polypropylene.
Additionally, we performed coronary artery bypass grafting (CABG) for
RCA using a saphenous vein graft. Cardiopulmonary bypass and operation
time was 160 and 279 minutes, respectively.

After the operation, we performed angiography again to detect the cause
of LA IMH. The angiography showed continuous extravasation of contrast
from the terminal LCX (Figure 3), and it was successfully treated with
embolization using two 15 mm coils.

The day after surgery, echocardiography showed the LA IMH (42 × 48 mm),
however, there was no pressure gradient through the mitral valve. In
addition, he remained hemodynamically stable. Because he had to receive
dual antiplatelet therapy (aspirin and clopidogrel) for the stent in the
coronary artery, we decided to pursue a watchful follow-up during
hospitalization. Serial echocardiography showed improving LA IMH (Figure
4). He was discharged on postoperative day 15.

One year after the surgery, CT showed no IMH in the LA (Figure 5).
Informed consent was obtained from the patient regarding the publication
of this case report.

\textbf{Discussion}

Intramural hematoma is an uncommon cause of LA mass {[}1{]}. There have
been several reports of LA IMH occurring as a complication of PCI and
ablation {[}1-5{]}.

Because the clinical course and outcome of LA IMH are poorly understood,
no definitive criteria exist to guide the management of this rare
entity. In case of hemodynamic stability, conservative management should
be selected {[}3{]}; otherwise, surgical treatment should be chosen if
patient is hemodynamically unstable. Hemodynamic instability is mainly
caused by functional MS.

Jothidasan et al. reported a case of LA IMH that was successfully
treated by surgically removing the clot {[}6{]}. In that case, the
patient had undergone CABG 19 years ago; therefore, an anterolateral
thoracotomy approach with small incision of the LA was selected. Cresce
et al. reported good results of surgical treatment of LA IMH with mitral
annular detachment, which was caused by the dissection of the atrial
wall {[}7{]}. In these case reports, no additional treatment for
coronary artery perforation was performed after evacuation of the
hematoma. We performed angiography after surgery to detect the cause of
LA IMH, and found continuous extravasation from the LCX. We believe that
a combination of surgery and interventional therapy should be considered
to prevent the recurrence of LA IMH. Moreover, long-term follow-up
should be performed, even if early postoperative hemodynamic status is
stable.

\textbf{Conclusion}

Left atrial intramural hematoma is a rare complication of percutaneous
coronary intervention. The combination treatment with surgery and
interventional therapy is one of therapeutic options in patients with
left atrial intramural hematoma after percutaneous coronary
intervention.

\textbf{Conflict of Interest:}

None declared

\textbf{Author Contributions:}

Drafting article: Jun Takaki, Kosaku NIshigawa, Takashi Yoshinaga, Ken
Okamoto

Critical revision: Toshihiro Fukui

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Gual-Capllonch F, Arce J, Serés L, et al. Left atrial intramural
  haematoma associated with mitral annular calcification. Eur J
  Echocardiogr. 2010;11:E18.
\item
  Franks RJ, de Souza A, Di Mario C. Left atrial intramural hematoma
  after percutaneous coronary intervention. Catheter Cardiovasc Interv.
  2015;86:E150-152.
\item
  Moradi B, Oraii S, Roshanali F, Ghorbanisharif A, Mikaeili J, Tahraei
  M. Conservative management of left atrial intramural hematoma after
  catheter ablation. Korean Circ J. 2016;46:580-583.
\item
  Sliman H, Shiran A, Rubinshtein R, Jaffe R. Left Atrial Wall Hematoma
  Simulating Severe Mitral Stenosis as a Complication of Percutaneous
  Coronary Intervention. JACC Cardiovasc Interv. 2019;12:1981-1982.
\item
  González Ferreiro R, Martín Moreiras J, Barreiro Pérez M, et al. Left
  Atrial Hematoma After Percutaneous Recanalization of Chronic Total
  Coronary Occlusion: Assessment With Cardiac Magnetic Resonance. JACC
  Cardiovasc Interv. 2019;12:e115-e117.
\item
  Jothidasan A, Attaran S, Hunter D, de Souza AC. Management~of
  a~left~atrial~intramural~hematoma~after~percutaneous~intervention. Ann
  Thorac Surg. 2014;97:2196-2197.
\item
  Cresce GD, Peluso D, Panfili M, et al. Left atrial wall hematoma as a
  consequence of percutaneous coronary angioplasty. Ann Thorac Surg.
  2012;93:e57-59.
\end{enumerate}

\textbf{Figure Legends}

Figure 1. Transthoracic echocardiogram showing an intramural hematoma
occupying left atrium preoperatively.

Figure 2. Preoperative computed tomography showing a large left atrial
mass.

Figure 3. Angiography showing perforation of the terminal left
circumflex artery (arrow).

Figure 4. Transthoracic echocardiogram showing the improvement in
hematoma postoperatively.

Figure 5. Follow-up computed tomography showing no mass in the left
atrium.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-4/Figure-4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fgiure-5/Fgiure-5}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

