Ann Thorac Surg 2005;79:1764-1765
© 2005 The Society of Thoracic Surgeons
Case report
Interventricular Septal Hematoma in Ventricular Septal Defect Patch Closure
Manuela Drago, MDa,
Gianfranco Butera, MD, PhDa,*,
Alessandro Giamberti, MDa,
Mariella Lucente, MDa,
Alessandro Frigiola, MDa
a Department of Pediatric Cardiology and Cardiac Surgery, Istituto Policlinico San Donato, San Donato Milanese, Italy
Accepted for publication October 24, 2003.
* Address reprint requests to Dr Butera, Department of Pediatric Cardiology and Cardiac Surgery, Istituto Policlinico San Donato, Via Morandi 30, 20098 San Donato Milanese, Italy
gianfra.but{at}lycos.com
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Abstract
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We report a case of interventricular septal hematoma after patch closure of a perimembranous ventricular septal defect in a 4-month-old infant. On postoperative day 1, echocardiography showed a voluminous intramural hematoma causing severe thickening of the ventricular septum. Surgical revision was necessary immediately to drain the hematoma.
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Introduction
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Various complications can occur after closure of a ventricular septal defect (VSD). These include thrombus formation, patch dehiscence, and complete atrioventricular block [1]. We report a case of interventricular septal hematoma after patch closure of a perimembranous VSD in an infant.
A 4-month-old infant was admitted to our department with a diagnosis of subaortic perimembranous VSD and a history of failure to thrive. On admission he weighed 4.2 kg. Physical examination showed perioral cyanosis during crying, a 4/6 pansystolic murmur with a left sternal border thrill, moderate tachypnea, and normal femoral pulses. Echocardiography showed a large subaortic perimembranous VSD with an interventricular pressure gradient of 35 mm Hg. The baby underwent surgical repair using aortobicaval cardiopulmonary bypass at moderate hypothermia (30°C) through a transatrial approach. During an aortic cross-clamp time of 22 minutes after blood cardioplegia infusion, the VSD was closed with a heterologous pericardial patch with continuous suture technique.
Three hours after the operation, signs of myocardial ischemia appeared (anterolateral ST-segment depression associated with increased levels of troponin and cardiac enzymes). Echocardiography showed no major abnormalities, and hemodynamic variables were stable. Twelve hours postoperatively, hemodynamic variables were highly instable, enzyme levels had increased further, and echocardiography showed severe thickening of the interventricular septum (posterior wall thickness in diastole, 15 mm) (Fig 1), global septal hypoakinesia, and right and left ventricular outflow tract obstruction.
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Fig 1. Two-dimensional echocardiographic long-axis view of the left ventricle on the first day after operation.
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The patient underwent immediate surgical revision. A voluminous intramural hematoma was found in a midmuscular position just below the VSD patch and the infundibular septum. The hematoma was incised in its central part, and the subendocardial thrombus was drained. Four additional stitches with pledgets were added to the pericardial patch edges closer to the hematoma to prevent dehiscence of the VSD patch. The patient underwent sternal closure on postoperative day 4 and was extubated on postoperative day 6. He was treated with inotropic agents (epinephrine and phosphodiesterase inhibitors) until postoperative day 8.
Subsequent postoperative echocardiographic evaluations showed a moderately increased septal thickness with a moderate hematoma in the septum, persistent septal motion anomaly, absence of an interventricular residual shunt, and no obstruction of the left ventricular outflow tract. Serial echocardiographic examinations demonstrated a spontaneous and substantial decrease in the residual hematoma. When the patient was discharged 20 days after the operation, the septal thickness was 5 mm, and the hematoma had been replaced by hyperechoc material (Fig 2).
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Fig 2. Two-dimensional echocardiographic long-axis view of the left ventricle showing an almost normal septal thickness 20 days after operation. The hematoma had been replaced by hyperechoic material.
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At 9 months' follow-up, there had been no complications, and the weight of the patient had increased markedly (9.5 kg at late follow-up). Echocardiography showed a normal septal thickness and only mild dyskinesia of the interventricular septum.
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Comment
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The occurrence of a hematoma in the interventricular septum is very rare. Ettles and associates [2] reported a case of acute hematoma formation in the interventricular septum after internal mammary artery grafting to the left anterior descending coronary artery. In that patient, the rapid extension of the hematoma caused severe left ventricular outflow obstruction leading to death. Di Bella and co-workers [3] reported two cases of postinfarction dissecting hematoma of the interventricular septum. Tejada Artigas [4], Traversat [5], and their colleagues described two cases of posttraumatic hematoma of the interventricular septum. Pliam and Sternlieb [6] reviewed the history of intramyocardial dissecting hematoma after myocardial infarction. They found 14 cases in the literature. Ninety percent of patients treated with a conservative approach died, whereas all patients treated surgically survived. Various complications after VSD closure have been reported [1], but we are not aware of previous descriptions of an intraseptal hematoma in this context.
In our patient, the signs of myocardial infarction followed by the rapid postoperative increase in the thickness of the interventricular septum suggest that bleeding from a septal branch of the anterior descending coronary artery may have occurred. However, we have no direct confirmation of this supposition. The indication for prompt drainage of the hematoma was the rapid worsening of clinical conditions and hemodynamic variables. The draining of the hematoma, although partial, improved the patient's clinical recovery. In conclusion, intraseptal hematoma is a complication that can develop after surgical VSD closure.
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References
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- Ventricular septal defect. In: Castaneda AR, Jonas RA, Mayer JE, Mayer JE Jr. Cardiac surgery of the neonate and infant. Philadelphia: WB Saunders, 1994:187–202
- Ettles DF, Firth N, Nair RU, Williams GJ. Fatal acute left ventricular outflow obstruction due to interventricular septal haematoma—diagnosis by transesophageal echocardiography. Eur Heart J. 1989;10:479–481[Abstract/Free Full Text]
- Di Bella I, Minzioni G, Maselli D, Pasquino S, Viganò M. Septal dissection and rupture evolved as an inferobasal pseudoaneurysm. Ann Thorac Surg. 2001;71:1358–1360[Abstract/Free Full Text]
- Tejada Artigas A, Laperal Mur JR, Caivo Cebollero I, Fernandez Gonzalez B, Gonzalez Manzanares JL, Placer Peralta L. Contusion and post-traumatic hematoma of the interventricular septum. Report of a case. [in Spanish]Rev Esp Cardiol. 1992;45:663–664[Medline]
- Traversat J, Laine JF, Slama M, et al. Cardiac contusion with dissecting hematoma of the apex of the heart and interventricular communication. [in French]Arch Mal Coeur Vaiss. 1986;79:1105–1109[Medline]
- Pliam MB, Sternlieb JJ. Intramyocardial dissecting hematoma: an unusual form of subacute cardiac rupture. J Card Surg. 1993;8:628–637[Medline]
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Eur J Echocardiogr,
October 1, 2007;
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395 - 398.
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Abstract
Introduction
