Dissecting hematoma of the interatrial septum

This is a 55 year-old female patient (#T285) undergoing a redo surgery for a flail of a mitral bioprosthesis, with positioning of a mitral bileaflet mechanical valve prosthesis.

At the intra-operative post-CPB TE examination a slowly expanding hematoma is seen dissecting the interatrial septum (Figures 1-4).
Redo surgery is known to carry a higher risk of complications.

The hematoma is initially described as infiltrating the left atrial wall, between the wall and the interatrial septum, posteriorly to the aortic root, in the short axis view of the base of the heart (upper esophagus Figure 1, white arrows), with a lower echogenicity (density) compared to the myocardium, and superior density compared to blood in the atrial cavity.

The mass is seen to expand in the following minutes (Figures 3-4, white arrows) and then to fill half of the interatrial septum in the 4-chamber view (Figure 4, white arrows). Given the high operative risk status (redo surgery) the surgeons decide not to re-enter CPB. The hemodynamic situation is stable.

This is the TE 3D rendering of the infiltratin hematoma of the interatrial septum (Figures 5-6). This is the cardiac base as seen from above (cranial view), by the surgeon (right side of the patient).

The heart structures visualised are: the right atrium (AD), the interatrial septum (setto interatriale), the left atrium (AS) in which (inferiorly) is seen the annulus of the bileaflet mitral valve mechanical prosthesis, the aortic root (Aorta). The hematoma (Ematoma) is clearly seen 10 minutes after the first appearance.