Abstract
Surgical septal myectomy is increasingly utilized for patients with hypertrophic obstructive
cardiomyopathy who remain symptomatic despite maximum doses of medical therapy. Deep
and extensive septal muscle resections may lead to iatrogenic ventricular septal defects
that are detected on transesophageal echocardiography immediately after weaning from
cardiopulmonary bypass and immediately corrected in the same surgery. However markedly
thinned out ventricular septum after myectomy may be prone to late rupture from high
left ventricular systolic pressures causing delayed detection of a ventricular septal
defect when the patients present with new onset symptoms. Additionally, a surgical
injury to the first septal perforator artery during the myocardial resection leading
to septal infarction may contribute to delayed occurrence of ventricular septal defect.
Such a predisposing deep septal resection or septal infarction may be associated with
varying degrees of atrioventricular nodal block warranting a permanent pacing. A new
onset interventricular shunt from such an iatrogenic ventricular septal defect often
leads to heart failure as the filling pressures increase disproportionately in the
thick hypertrophied left ventricle. Transcatheter closure is an alternative to a high-risk
repeat surgery. This report of device closure of two delayed septal ruptures after
myectomy discusses the reasons, presentation, catheter approaches, and procedural
challenges.
<Learning objective: Deep extended septal myectomy for medically refractory hypertrophic obstructive cardiomyopathy
may lead to early or late iatrogenic ventricular septal defect. Such an extensive
loss of septal muscle may be additionally indicated by co-occurrence of atrioventricular
nodal block that needs permanent pacing. Heart failure from the new onset interventricular
shunt is not clinically tolerated by the hypertrophied left ventricle due to elevated
end diastolic pressures. Transcatheter closure of the ventricular septal defect is
an attractive alternative to a morbid repeat surgery.>
Keywords
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Article info
Publication history
Published online: December 30, 2021
Accepted:
November 17,
2021
Received in revised form:
November 4,
2021
Received:
September 29,
2021
Identification
Copyright
© 2021 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
