Khameneh-Bagheri Ramin, Jafarzadeh-Esfehani Reza, Ahmadi Mostafa
Assistant Professor, Department of Cardiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
PhD Candidate, Department of Medical Genetics, School of Medicine, Mashhad University of Medical Sciences, Mashhad AND Researcher, Student Research Center, Sabzevar University of Medical Science, Sabzevar, Iran.
ARYA Atheroscler. 2017 Sep;13(5):253-256.
The interventricular septal hematoma (IVSH) is a rare and potentially lethal finding. There are variously reported etiologies including instrumental damages during cardiac interventions. Although there are not enough studies available, conservative management is considered as a preferable approach in stable patients.
A 45-year man smoker with the previous history of percutaneous coronary intervention (PCI), admitted with unstable angina in present visit. Coronary angiography showed significant in-stent restenosis (ISR) of the left anterior descending (LAD) artery stent. During our intervention for treatment of the ISR, the wire movement caused a diffuse dissection without any runoff, in the distal portion of the LAD. Therefore two stents were deployed in the dissected segment with a short overlapping segment. Unfortunately, the overlapping segment of these stents was located in the myocardial bridge segment. Therefore the contraction of the interventricular septum (IVS) caused a scissor-like movement of the stents, and they ruptured the LAD into the septum. Therefore, the contrast agent was accumulated in the IVS. Immediately, a graft stent was deployed in the overlapping segment of stents and perforation became sealed. In echocardiography, the IVS diameter increased to 30 mm. Since the patient was hemodynamically and electrically stable, he underwent conservative approach and after two months the septum returned to the normal size.
During PCI on the LAD artery, the implantation of stents in the septal course with a short overlapping segment can result in coronary perforation, and therefore IVS hematoma by the scissor effect. Septal hematoma may cause life-threatening arrhythmias or ventricular septal rupture, but if it is asymptomatic or uncomplicated. Conservative management is the best strategy.
室间隔血肿（IVSH）是一种罕见且可能致命的表现。病因报道多样，包括心脏介入操作中的器械损伤。尽管现有研究不足，但对于病情稳定的患者，保守治疗被认为是一种较好的方法。
一名45岁男性吸烟者，既往有经皮冠状动脉介入治疗（PCI）史，此次因不稳定型心绞痛入院。冠状动脉造影显示左前降支（LAD）动脉支架存在严重的支架内再狭窄（ISR）。在我们对ISR进行干预治疗时，导丝移动导致LAD远端出现无血流的弥漫性夹层。因此，在夹层段置入了两枚支架，并有一小段重叠。不幸的是，这些支架的重叠段位于心肌桥部位。因此，室间隔（IVS）的收缩导致支架出现剪刀样运动，致使LAD穿破进入室间隔。于是，造影剂积聚在IVS内。随即，在支架重叠段置入一枚移植物支架，穿孔得以封闭。超声心动图检查显示IVS直径增至30 mm。由于患者血流动力学和电活动稳定，故采取保守治疗方法，两个月后室间隔恢复至正常大小。
在LAD动脉进行PCI时，在室间隔走行处短重叠段置入支架可能导致冠状动脉穿孔，进而因剪刀效应引发IVS血肿。室间隔血肿可能导致危及生命的心律失常或室间隔破裂，但如果无症状或无并发症，保守治疗是最佳策略。
