Left atrial inflow and outflow obstruction as a complication of retrograde approach for chronic total occlusion

Retrograde recanalization of a chronic coronary total occlusion has become an increasingly utilized method to increase success from percutaneous coronary intervention (PCI). Retrograde wire passage using a septal collateral is the preferred route as the consequences of vessel perforation are more benign than epicardial collateral perforation which may produce cardiac tamponade. Tamponade risk is thought to be lessened by previous coronary bypass surgery due to adhesions preventing free flow of blood throughout the pericardial space. We report the first case of the retrograde approach producing epicardial collateral perforation resulting in a localized epicardial hematoma, which in turn, produced left atrial (LA) inflow and outflow obstruction, with the former producing localized pulmonary edema and pleural effusion. We review reported cases of LA hematoma as a consequence of the antegrade PCI approach and describe a unified explanation for the development of this phenomenon. © 2012 Wiley Periodicals, Inc.