case_images: PMC5833259_01
case_images: (a) Severe stenosis of the mid circumflex artery before intervention. The circumflex provides collaterals to the RCA. (b) Persistent "waisting" (stenosis) after dilating with a 2.5 mm compliant balloon. (c) Loss of waist after inflation of a 2.5 mm AngioSculpt balloon. (d) Ellis III perforation after dilation with a 2.5 mm scoring balloon.
case_images: CRIC2018-8676572.001.jpg
case_images: PMC5833259_01_CRIC2018-8676572.001.jpg
case_images: fig1
case_images: There was severe stenosis of the native left circumflex artery (Figure 1(a)); the proximal right coronary artery was completely occluded, and it was supplied distally by bridging collaterals and collaterals from the left circumflex artery. Serial balloon dilation to the mid circumflex artery was performed: first with a 2.5 mm x 15 mm balloon but a waist was noted (Figure 1(b)), followed by a noncompliant 2.5 mm x 12 mm balloon but a residual waist was still observed, and finally with a 2.5 mm x 10 mm scoring balloon (AngioSculpt, Spectranetics, Milwaukee, Wisconsin, USA) inflating up to 20 atmospheres (Figure 1(c)). The stenosis gave way, and repeat angiogram noted Ellis Class III perforation (Figure 1(d)).
case_images: ECG showing ST elevation in inferior leads.
case_images: CRIC2018-8676572.002.jpg
case_images: PMC5833259_01_CRIC2018-8676572.002.jpg
case_images: fig2
case_images: The ECG showed fast atrial fibrillation with acute ST elevation in II, III and aVF (Figure 2).
case_images: (a) Emergency transthoracic echocardiogram showing accumulation of hematoma around the coronary sinus and atrioventricular groove. (b) Pulse Doppler in the apical 4-chamber view across the mitral valve showing elevated mean pressure gradient of 8 mmHg, suggesting functional mitral stenosis secondary to compression of the left atrium and mitral valve apparatus.
case_images: CRIC2018-8676572.003.jpg
case_images: PMC5833259_01_CRIC2018-8676572.003.jpg
case_images: fig3
case_images: Repeat assessment by echocardiogram showed no increase in pericardial effusion, but there was a new collection of fluid at the atrioventricular groove (Figure 3(a)), compressing on the left atrium. Doppler echocardiography showed an increased mitral inflow gradient of 8 mmHg, suggesting functional mitral stenosis (Figure 3(b)).
case_images: (a) Cannulation of the coronary sinus with an AL-1 catheter and hydrophilic wire. (b) Contrast injection through the AL-1 catheter showing compression and no flow of the coronary sinus.
case_images: CRIC2018-8676572.004.jpg
case_images: PMC5833259_01_CRIC2018-8676572.004.jpg
case_images: fig4
case_images: Coronary sinus cannulation was attempted (Figure 4(a)), and the venogram showed no flow in coronary sinus (Figure 4(b)), suggesting extrinsic compression of the coronary sinus.
case_images: CT chest showing large hematoma arising from atrioventricular groove, with contrast from coronary angiogram, compressing on left atrium. The coronary sinus cannot be seen in the scan due to severe extrinsic compression. The arrow shows the ECMO cannula at the superior vena cava and right atrium junction.
case_images: CRIC2018-8676572.005.jpg
case_images: PMC5833259_01_CRIC2018-8676572.005.jpg
case_images: fig5
case_images: An urgent computed tomography scan was performed confirming the presence of the large 7.6 cm x 3.9 cm collection in the posterior aspect of the mediastinum extrinsically compressing and displacing the left atrium superiorly and to the right (Figure 5).