An 82-year-old UAE national, who underwent cardiac catheterization procedure at Al Ain Hospital, developed coronary artery perforation during cardiac catheterization. Emergency covered stent grafting was done and perforation was closed. But unfortunately, the patient developed acute cardiac tamponade and needed resuscitation. Initially 100 ml of blood was drained from the pericardium percutaneously, but the patient’s condition did not improve and he went into cardiogenic shock. He was intubated and IABP was introduced with heavy inotropic support.
The patient was shifted for emergency cardiac surgery and drainage of cardiac tamponade. The patient’s history revealed ischemic heart disease, diabetes, hypertension, past history of smoking, with recent unstable angina. He was admitted with chest pain as NSTEMI at Al Ain Hospital. He had previous coronary angiogram in 2019 which showed double vessel disease and stenting was done to LAD and circumflex arteries. This time, in view of his unstable angina, he was taken up for diagnostic angiography and possible intervention. On admission to our hospital, he was in cardiogenic shock, on heavy inotropic support, ventilated and on IABP with poor hemodynamics. Preoperative transesophageal echocardiogram in the operation theatre revealed significant cardiac tamponade, ejection fraction 25%, dyskinetic apical and septal region, calcified aortic valve and presence of a large atheroma in distal aortic arch. He was taken up for emergency CABG and pericardial drainage was done. On opening the pericardium, almost 200 mL blood was drained and his hemodynamics improved. In view of the large mobile atheroma in the aortic arch, it was decided to do the coronary bypass grafting on OFF PUMP beating heart. On opening the LAD, there were fresh clots in both distal and proximal areas. A size 3 Fogarty balloon catheter was introduced to both proximal and distal LAD to remove the clots. Then single saphenous vein graft was done to mid LAD. He remained in on IABP and inotropic support with stable hemodynamics. All the supports were weaned off on the second post-operative day and IABP was removed. He was discharged on 12th post-operative day with no neurological deficit.
Discussion
Coronary artery perforation during cardiac interventions, is a rare complication in the present era. Advanced hardware, safety measures and highly experienced interventional cardiologists has brought down this complication to less than 0.3%. But when it occurs, if further interventional procedures fail, surgical treatment is the only alternative. For that, surgical team and the facility should be available at short notice to save the life of the patient.
