Dissecting sub-epicardial hematoma--challenges to surgical management

A 67-year-old man developed a large dissecting sub-epicardial hematoma of his heart following a percutaneous coronary interventional procedure. While undergoing a dilatation of in-stent restenosis of a saphenous vein graft to the diagonal artery, he developed an anastomotic perforation that lead to a large sub-epicardial hematoma that sheared of all the epicardial vessels from the underlying myocardium. Emergent surgery was performed as he began to evolve a large myocardial infarction. Evacuation of the hematoma and gluing back of the epicardium was the only operation possible due to the complexity of the problem. Deteriorating hemodynamics post-operatively led to the placement of a percutaneous ventricular assist device despite which he succumbed. This case report is intended to alert the surgical community to such a rare complication of aggressive percutaneous intervention, difficulty in establishing an accurate diagnosis and repairing the sub-epicardial dissecting hematoma.