CAR-7. Left atrial appendage perforation during coronary artery angioplasty.

A 70-year-old woman was admitted to the hospital with chest pain. She was placed on aspirin, clopidogrel, enoxaparin, and tirofiban in addition to beta blocker and statin therapy. She ruled in for myocardial infarction. A left heart cath, revealed the culprit lesion to be a totally occluded left circumflex artery. After unsuccessful attempts to cross the lesion with a multiple wires, the lesion was crossed with an intermediate (stiff) wire and angioplasty (PTCA) with stent placement was done successfully. The patient became hypotensive 1 hour after the intervention and an echocardiographic study done at the bedside revealed a large pericardial effusion with impending tamponade. The patient was rushed to the operating room and a large hemopericardium was found, the source of which was a perforation in left atrial appendage. The perforated appendage was successfully sutured. The patient survived and had an uneventful post-operative course. On subsequent review of the post intervention angiography, a thin film of pericardial effusion is seen in the final angiographic image. The perforation occurred in the context of multiple attempts to cross the totally occluded circumflex artery, as the wire most likely dissected the circumflex artery and penetrated the left atrial appendage. Although coronary perforation is a recognized complication of PTCA, left atrial perforation has not been reported in the literature as a complication of this procedure. Coronary perforation is an important problem, for which advanced age, diabetes, female gender, (GP IIb IIIa) inhibitors, and the use of ablative devices (like rotablator and directional atherectomy) seem to be the key risk factors. The incidence of perforation with PTCA and stenting appears to be 0.1-0.3%. These events typically happen in three settings: (1) Distal guidewire migration in the presence of strong antiplatelets therapy; (2) vigorous probing of totally occluded vessel with a stiff or a hydrophilic wire in the presence of GP IIb IIIa inhibitors therapy (this risk can be minimized by starting GP IIb IIIa inhibitors after crossing the totally occluded vessel); (3) high-pressure stenting, which is rarely used with the newer stents. It is important to recognize that hemodynamic deterioration occurs acutely at the time of the intervention in 50% of the cases, while the other cases develop subacutely a few hours after the intervention. Thus perforation and tamponade should remain high on the list of causes of post procedural hypotension (along with ischemia, bleeding, vagal reaction, and drug reaction).

Nezar Falluji, Elie Gharib, and Mark Studeny. Department of Cardiovascular Services, Joan C. Edwards School of Medicine, Huntington, WV.