Chronic intramyocardial dissecting haematoma: multimodality imaging Free

A 58-year-old man, with a history of hypertension and smoking, was referred for cardiology consultation because of a large anterior Q wave in his electrocardiogram. He was asymptomatic, but 3 years earlier he had a car accident after a syncope without seeking medical attention. Transthoracic echocardiography (TTE) showed mildly reduced left ventricular (LV) ejection fraction (42%), apical akinesia, and an image suggestive of apical thrombus (see Supplementary data online, Figure S1). Cardiac computed tomography angiography (CCTA) was performed for further evaluation, but it was not clear whether the structure shown represented a LV mural thrombus or an intramyocardial dissecting haematoma (IDH) (see Supplementary data online, Figure S2). Cardiovascular magnetic resonance confirmed the diagnosis of a chronic IDH by showing a heterogenous hypointense mass surrounded by late gadolinium enhancement (LGE) and separated from the LV cavity by a thin line of LGE (Figure 1A–D and Supplementary data online, Figures S3 and S4). Coronary angiography confirmed a subocclusive stenosis in the mid segment of the left anterior descending artery (see Supplementary data online, Video S1). Considering the patient’s clinical stability, a conservative approach with guideline-directed medical therapy was adopted. The patient remains asymptomatic at 6 months follow-up.

Figure 1

Cardiovascular magnetic resonance characterization of a chronic intramyocardial dissecting haematoma. (A) Still frame of cine cardiovascular magnetic resonance (steady-state free precession sequence; two-chamber view) showing a heterogenous hypointense apical mass, with a thin isointense line towards the left ventricular cavity. (B–D) Late gadolinium enhancement cardiovascular magnetic resonance images [two-chamber (B), three-chamber (C), and four-chamber (D) views, respectively] establishing the diagnosis of a chronic intramyocardial dissecting haematoma by showing a heterogenous hypointense mass at the left ventricular apex surrounded by late gadolinium enhancement between the mass and the pericardium, as well as a thin line of hyperenhancement between the mass and the left ventricular cavity. CMR, cardiovascular magnetic resonance; IDH, intramyocardial dissecting haematoma; LGE, late gadolinium enhancement; LV, left ventricle/cular.

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Intramyocardial dissecting haematoma is a rare complication of myocardial infarction, chest trauma, or reperfusion procedures.^1–3 Delayed presentation can mimic LV intracavitary thrombus on TTE and CCTA.^1,4 Cardiovascular magnetic resonance is crucial to establish the final diagnosis by identifying the endocardial and epicardial layers surrounding the haematoma.^1,2,5 Management of chronic IDH depends on multiple factors, including patient’s haemodynamic stability, size of haematoma, and expansion of dissection.^1,2

Supplementary data is available at European Heart Journal online.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

All authors declare no funding for this contribution.

Written informed consent has been obtained from the patient to publish this paper.

Author notes