An 80 year old man presented with unstable angina four weeks after undergoing two vessel coronary artery bypass surgery. Percutaneous transluminal coronary angioplasty of an ungraftable circumflex artery was complicated by a coronary artery perforation. The patient was initially stable but after several hours developed haemodynamic instability. Transthoracic and later intraoperative transoesophageal echocardiography revealed a large isolated haematoma in the oblique sinus compressing the posterior left atrium (A, short axis view through the aortic valve; AO, aortic valve; LA, left atrium; RA, right atrium; TH, thrombus). An emergency left posterior left thoracotomy was performed and the thrombus evacuated with relief of the left atrial compression (B). No further cardiac intervention was required and the patient was successfully discharged.

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