A 59 year old man was admitted with typical chest pain, electrocardiographic findings of acute anterior wall STEMI, and elevated serum troponin level. On admission, he was hemodynamically stable. Primary Coronary angiography revealed thrombotic subtotal occlusion at the ostium of the LAD artery involving the LCX artery ostium with a hazy filling defect and TIMI flow grade III.
Aspiration thrombectomy only relieved the occlusion in the LAD vessel, and intra-aortic balloon counter-pulsation was applied for 24 hours. Medical therapy with aspirin, prasugrel and unfractionated heparin was initiated. Echocardiographic study showed antero-apical akinesis with estimated LVEF of 25%.
On third hospitalization day, echocardiographic study showed improvement of LVEF to 35%, and normal cardiac chambers. On fourth hospitalization day, he developed an atrial fibrillation episode terminated by intravenous amiodarone. Consequently, warfarin treatment was initiated and prasugrel was changed to clopidogrel.
Given the lesion nature at the LCX artery ostium, a repeat coronary angiography performed on 7 hospitalization day revealed a border line lesion. Uneventful FFR measurement gave a result of 0.95.
On hospitalization day 12, patient reported on mild chest pain and dyspnea. Echocardiographic study revealed a new large mass adherent to the posterior left atrial wall. Surgical exploration revealed a large left atrial wall hematoma which was excised. Its histological examination revealed fragments of fresh thrombus with scattered myocardial fibers.
Although left atrial wall hematoma seems to develop spontaneously under of triple anticoagulation therapy, insertion of FFR wire into the LCX artery may contributed to the development of the hematoma.
