Interventricular septal hematoma detected by transesophageal echocardiography after congenital heart surgery in an infant: a case report

Abstract

Background Interventricular septal hematoma is an extremely rare complication following congenital heart surgery. During cardiac surgery, interventricular septal hematomas can be detected only by intraoperative transesophageal echocardiography. Here, we report an interesting case of interventricular septal hematoma that was accidentally found in an infant following ventricular septal defect (VSD) closure. Case presentation Transesophageal echocardiography images were acquired from a 1-month-old boy after surgical repair of a large (6.5 mm) perimembranous outlet VSD with interventricular septal flattening. Surgical correction was performed with auto-pericardium and 7–0 Prolene sutures. The patient was successfully weaned from cardiopulmonary bypass, and transesophageal echocardiography showed no VSD leakage and good ventricular function. However, approximately 30 min later, two anechoic masses were found within the interventricular septum, which were suspected to be interventricular septal hematomas; the larger mass measured 1.51 $$\times $$ × 1.48 cm. The swollen interventricular septum showed decreased contractility and compressed both the right and left ventricles. However, there was no change in the size of hematomas or a significant hemodynamic instability for 30 min of observation. Therefore, expecting spontaneous resolution of the hematomas, the interventricular septum was not explored, and the patient was removed from cardiopulmonary bypass. On postoperative day 4, follow-up transthoracic echocardiography revealed thrombi filling the hematomas. The patient was discharged on postoperative day 15 and followed up with regular echocardiographic evaluations. Conclusions We describe a unique case of interventricular septal hematoma after VSD closure. Surgical manipulation of perimembranous VSD and injury of the septal perforating artery may contribute to the development of an interventricular septal hematoma. Moreover, conservative treatment and serial echocardiographic evaluation generally show gradual hematoma resolution in hemodynamically stable patients. Pediatric cardiac anesthesiologists should be aware of this rare complication after VSD repair.

Interventricular Septal Hematoma Following Correction of Ebstein Anomaly

“… 8 The limited literature on postoperative IVSH is mostly related to VSD repair, and the IVSH was always detected by TTE or TEE soon after the surgery, which can be explained by the septal perforating artery injury. 3 , 5 , 9 The theory does not hold true in our patient since there was no VSD closure and intraoperative TEE did not reveal any hematoma. In our patient, a cavity was formed after anchoring the delaminated endocardium to the true tricuspid annulus.…”

“…The leading theory is that injury of the septal perforating artery contributes to the development of IVSH. 5 This vessel is at risk during suturing since it is close to the anterior-superior margin of the VSD. The use of anticoagulation therapy and cardiac compression during operation may also contribute to the hematoma formation.…”

Interventricular Septal Hematoma Complicating Ventricular Assist Device Placement in an Infant: Case Report and Review of the Literature

“…Microvascular sheering from surgical trauma, high cardioplegia perfusion pressure, and high preoperative right ventricular pressure has also been implicated. 10 It is unclear what caused the septal hematoma in our patient. Although bleeding from septal arteries could have arisen from the apical ventriculotomy or sutures placed to secure the sewing ring, the hematoma appeared to arise in the mid-basilar portion of the ventricular septum.…”

“…Microvascular sheering from surgical trauma, high cardioplegia perfusion pressure, and high preoperative right ventricular pressure has also been implicated. 10…”

“…IVSH is a rare and potentially lethal complication of pediatric cardiac surgery, with 36 cases reported in the literature since the initial report by Drago and colleagues in 2005. [1][2][3][4][5][6][7][8][9][10][11][12] The IVSH can cause ventricular outflow tract obstruction, arrhythmias, ventricular dysfunction, and myocardial rupture leading to hemodynamic compromise. This complication is commonly associated with ventricular septal defect repair 1 and may be due to injury to the septal perforator artery, which courses across the lower border of the anterior limb of the septomarginal trabeculation and terminates at the base of the medial papillary muscle of the tricuspid valve.…”