75 year-old-man was presented at Emergency department after falling from the second floor. Left-sided rib fractures with haemothorax and pneumothorax (Figure 1), and hemoperitoneum were diagnosed. ECG showed sinus rhythm, pathologic R-wave progression in V1-4 and repolarization abnormalities (Figure 2). Echocardiography revealed left ventricle (LV) with normal size and ejection fraction (EF) 53%. There were no cardiac mechanical complications and pericardial effusion. Lung drainage and abdominal laparoscopy performed immediately.
Figure 1. Chest X-ray at admission.
On the next day patient represented with hypotension, high dose catecholamine infusion was started to maintain RR 90-95/60 mmHg. There was no breathing in the left chest and new systolic murmur with punctum maximum at the left lower sternal edge was heard. High-sensitivity Troponin I reached 416 pg/ml. Echocardiography revealed LV apical dyskinesia and additional cavity with systolic expansion and thin wall, separated from LV cavity – intramyocardial dissecting hematoma (Figure 3). No color Doppler flow was visualized in this structure (Figure 4). Lateral wall was hypokinetic, EF dropped to 35%. There was a huge mass with characteristic of pleural hematoma with severe compression of left atrium (Figure 5). Mitral inflow was reduced with E-wave 48 cm/s and E/A ratio 1.1. Severe tricuspid regurgitation was registered. The patient died on the 10-th day because of progressing respiratory and heart failure despite improved LV function and absence of pericardial effusion.
Figure 2. ECG at admission.
Figure 3. 2D-echocardiography, left ventricular apex with intramyocardial dissecting hematoma.
Figure 4. Short axis apical view, additional cavity (intramyocardial hematoma) without color Doppler flow.
Figure 5. 3-chamber apical view, large pleural hematoma behind left ventricular posterior wall with compression of left atrium.
This case represented a rare combination of blunt cardiac injury with intramyocardial dissecting hematoma and heart compression from large pleural hematoma, which should be considered in polytrauma.
