Inoperable Retroatrial Hematoma Causing Shock After PCI

BACKGROUND: Loculated retroatrial hematoma is a rare but potentially fatal complication of coronary perforation. In patients with prior coronary artery bypass graft surgery (CABG), pericardial adhesions may prevent the development of classic circumferential tamponade and instead result in localized cardiac chamber compression with delayed hemodynamic collapse. CASE SUMMARY: A 76-year-old woman with prior CABG underwent high-risk distal left main and left circumflex percutaneous coronary intervention complicated by proximal left circumflex artery perforation, which was successfully sealed with 3 covered stents. Despite initial stabilization, progressive shock developed several hours later. Echocardiography and computed tomography angiography demonstrated a loculated retroatrial/posterior pericardial hematoma measuring approximately 50 × 40 mm with marked left atrial compression. Surgical revision was declined by 2 tertiary cardiac surgery centers because of previous CABG, ongoing hemodynamic instability, and the anticipated complexity of redo cardiac surgery. Conventional subxiphoid drainage was unsuccessful. A stepwise epicardial bailout strategy involving adhesiolysis, large-bore access escalation, and aspiration using a 20-F Triever catheter resulted in evacuation of organized hematoma, immediate hemodynamic recovery, and complete avoidance of surgery. DISCUSSION: In selected post-CABG patients with shock caused by retroatrial hematoma, when surgery is not feasible and conventional drainage fails, large-bore epicardial aspiration may provide a lifesaving bailout option.