A fast-growing obstructive left atrial intramural hematoma causing acute prolonged chest pain

A 74-year-old woman was at the emergency department for acute chest pain, dyspnea and severe transient hypotension. History was arterial hypertension and external electrical cardioversion (EEC) for persistent atrial fibrillation (AF) 8 days before admission. At that time echocardiography was normal. The patient underwent coronary angiography with no evidence of significant coronary arteries disease. At echocardiography a large multi-loculated mass occupying most of the left atrial space and obstructing left ventricular inflow was evident. There was mild pericardial effusion. The patient was operated and a large thrombus totally encompassed in the left atrial wall was removed. Initial tearing into the pericardial space was revealed. Post-surgical follow-up was uneventful and at 3-6 months normalization of the atrial cavity with blending of atrial endocardium and epicardium was demonstrated. No apparent etiological factor was found. We have provided evidence of the possible rapid formation of a large intramural atrial hematoma. Spontaneous atrial wall dissection should be considered in the differential diagnosis of chest pain.