Dr. Ritesh Gangwar
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Case study · Echo

A bleed inside the heart wall

Intramyocardial dissecting hematoma (IDH), explained in plain words

A rare problem that usually follows a heart attack. Blood forces its way between the layers of heart muscle and fills a pocket inside the wall. Here is what it looks like on an echo, why it happens and what doctors do about it.

Dr. Ritesh Gangwar · · 5 min read

The echo from this case: an ultrasound video of the heart. Patient details have been removed.

01

First, the heart wall

The walls of the heart's main pumping chamber are made of muscle, about a centimetre thick. The muscle is wound in layers, like the strands of a rope, and it is lined on both sides: a smooth inner lining that touches the blood, and an outer lining on the surface.

A cross-section of the heart wall: blood inside the chamber, the inner lining, the muscle in layers, the outer lining. Blood Inner lining Muscle Outer lining Outside the heart Damaged muscle Blocked artery Pocket of blood

Muscle fibres wound in layers, with a smooth lining on the inside and on the outside.

Illustration to explain, not to scale.

02

What the echo shows

An echo is an ultrasound scan of the heart. It shows the heart beating, in real time, from different angles. These are the views from this case. Tap one to jump to it.

Black: bloodGrey-white: muscle, valves and other tissue

What doctors look for

A hollow space inside the muscle

A new dark space within the wall itself, not inside the chamber.

A thin, moving lining

The inner lining over the pocket can look thin, and may move with each beat.

Change over time

Repeat scans show the pocket changing: the blood clots and is slowly absorbed, or the pocket grows.

An MRI scan of the heart is often used to confirm it, because it can tell blood apart from muscle and from a blood clot.

03

Why it matters

IDH is a kind of contained tear. The wall has split on the inside, but its linings are holding. The pocket can grow, and in some patients the wall can tear through. That is why doctors watch it closely.

It is rare. Most people who have a heart attack never develop it.

04

What happens next

When the patient is stable

Close watch

If the patient is stable, many are treated with medicines and watched closely, with repeat scans to check that the pocket is not growing. In some, the blood is slowly absorbed.

When it is needed

Surgery

If the pocket grows, the blood pressure falls, fluid collects around the heart or a hole opens between the chambers, surgery may be needed.

Every patient is different. The heart team decides together, case by case.

05

After a heart attack, tell your doctor if you have

  • Breathlessness that is new or getting worse
  • Chest pain that comes back
  • Dizziness, fainting or feeling very weak
  • A racing or irregular heartbeat
  • Swelling in the feet or legs

Keep the follow-up visits and scans your doctor asks for.

Chest pain or breathlessness right now? Go to the nearest emergency department at once, or call Dr. Ritesh's 24×7 emergency line: +91 63926 29346

For doctorsDefinition, echo criteria, differentials and management

Definition

IDH is a dissection of the myocardium by hemorrhage tracking between the spiral myocardial fibres, creating a blood-filled neocavity bounded by intact endocardium and epicardium. It is regarded as a form of subacute, incomplete cardiac rupture.4

Setting

Most reported cases follow acute myocardial infarction: 58 of 77 (75.3%) in a 2024 pooled analysis.1 In Leitman's series, 66% of post-MI cases followed anterior infarction.2,4 It is also described after PCI, CABG, ablation and chest trauma, and occasionally without a trigger. The LV free wall, the interventricular septum and the RV free wall can all be involved.1,4

Echo clues

Published criteria look for several of the following together:3,5

  • one or more neocavities with an echo-lucent centre
  • a thinned, mobile endomyocardial border around the cavity
  • myocardium preserved outside the cystic area
  • echogenicity changes suggesting blood content
  • partial or complete resorption on follow-up
  • continuity with a ventricular cavity, or communication between the ventricles
  • Doppler flow within the dissected myocardium

Contrast echo helps define the endocardial border, and TEE helps when transthoracic windows are poor.4

Differentials

LV thrombus (on the endocardial surface, within the cavity), prominent trabeculations, pseudoaneurysm (a full-thickness rupture contained by pericardium), post-infarct ventricular septal rupture and free-wall rupture.4,5

Confirmation

CMR is regarded as the reference standard in stable patients: cine imaging for the cavity and any communication, and tissue characterisation and gadolinium sequences to separate hematoma from thrombus.4

Management

There is no guideline-defined strategy, and the evidence is limited to case reports and small series.1,4 Stable patients are often managed conservatively with close serial imaging. Surgery is considered for hemodynamic instability, an expanding hematoma, pericardial effusion or ventricular septal rupture. Decisions are individualised, ideally by a heart team.4

Outcomes in the literature

In the pooled analysis, 26 of 77 patients (33.8%) died; older age and pericardial effusion (odds ratio 3.92) were associated with higher mortality.1 Leitman and colleagues found LVEF below 35%, age over 60 and delayed diagnosis to predict in-hospital mortality.4

Take-home

After an MI, a new echo-lucent space within the wall deserves a second look before it is called a thrombus. Serial echo, and CMR when the patient is stable, settle the diagnosis and guide the choice between watchful management and surgery.

References

  1. Zavar R, Soleimani A, Tajmirriahi M, et al. Intramyocardial dissecting hematoma: a systematic review and pooled analysis of available literature. ARYA Atheroscler. 2024;20(1):62-71. PMC11331553
  2. Leitman M, Tyomkin V, Sternik L, et al. Intramyocardial dissecting hematoma: two case reports and a meta-analysis of the literature. Echocardiography. 2018;35(2):260-266. doi:10.1111/echo.13796
  3. Vargas-Barrón J, et al. Dissecting intramyocardial hematoma: clinical presentation, pathophysiology, outcomes and delineation by echocardiography. Echocardiography. 2009;26(3):254-261.
  4. Yu Q, Zhou C, Liu R, Bao R. Clinical significance of intramyocardial dissecting hematoma after MI: a review. Medicine (Baltimore). 2025;104(44):e45650. PMC12582815
  5. Tanabe J, Okazaki K, Endo A, Tanabe K. Left ventricular intramyocardial dissecting hematoma. CASE (Phila). 2021;5(6):349-353. PMC8712951

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