Extracorporeal membrane oxygenation as a novel management strategy for interventricular septal hematoma following ventricular septal defect repair

Evolution of Interventricular Septal Hematoma: Echocardiographic Diagnosis

“…This results in subendocardial bleeding, and further expansion of the hematoma occurs due to anticoagulation. 4,11 However, this theory does not hold true in two reported cases where IVSH developed without VSD closure, one following relief of pulmonary atresia/critical stenosis with intact ventricular septum and the other following repair of total anomalous pulmonary venous return and atrial septal defect closure. The pathogenesis in the former case is thought to be due to hypertensive right ventricular pressures associated with endocardial fibroelastosis and coronary artery ischemia, and in the latter case due to possible high cardioplegia perfusion pressure leading to impaired myocardial perfusion.…”

“…Complications of IVSH include decreased right and left ventricular systolic and diastolic function, myocardial rupture, thrombus formation, abscess formation, right and left ventricular outflow tract obstruction, 2 conduction system abnormalities including heart block, junctional tachycardia, cardiac tamponade, requirement of extracorporeal membrane oxygenation support, and risk for multiorgan dysfunction and mortality. 4 The mortality reported in the adult literature is higher, ranging up to 78%, especially in those managed convervatively. 13 In comparison, the mortality reported in the pediatric literature is lower at 33% (in 12 pediatric patients after VSD closure); 16% (two cases) needed an intervention to drain the hematoma.…”

“…The pathogenesis in the former case is thought to be due to hypertensive right ventricular pressures associated with endocardial fibroelastosis and coronary artery ischemia, and in the latter case due to possible high cardioplegia perfusion pressure leading to impaired myocardial perfusion. 10,12 Jegatheeswaran et al 4 reported a series of 12 pediatric patients who developed IVSH after VSD closure. They identified that those under 2 months of age and median weight of 3.4 kg may be at higher risk of IVSH likely attributed to the difficulty in visualization of the defect.…”

“…They identified that those under 2 months of age and median weight of 3.4 kg may be at higher risk of IVSH likely attributed to the difficulty in visualization of the defect. 4 Among their 12 cases, 75% developed IVSH after a single cardiopulmonary bypass, while the remainder of the cases occurred following two bypass runs.…”

“…3 Often IVSH causes hemodynamic compromise and is associated with significant morbidity and mortality. 4 Commonly reported complications of IVSH include myocardial rupture, ventricular dysfunction, ventricular outflow tract obstruction, and abscess formation. The hematoma leading to coronary cameral fistula has been previously reported after stent placement in a coronary artery.…”