Iatrogenic Ventricular Septal Defect Research Articles

Results of operation for coexistent obstructive hypertrophic cardiomyopathy and coronary artery disease

This study describes the operative management and outcome of 28 patients with obstructive hypertrophic cardiomyopathy and hemodynamically significant coronary artery disease. Each patient underwent coronary artery bypass grafting and concomitant left ventricular myotomy-myectomy or mitral valve replacement. The mean age at operation was 59 years (range 42 to 74).Five patients (18%) died as a result of operation, four in the immediate postoperative period and one at 2 months postoperatively. Three patients died after the immediate postoperative period of causes unrelated to the operation. The mean follow-up period for the 20 currently surviving patients was 4.8 years (range 4 months to 10.8 years). Nineteen of these patients have experienced substantial functional improvement; all are currently asymptomatic or only mildly symptomatic.Twenty-one patients underwent cardiac catheterization before and after operation; each experienced relief of left ventricular outflow tract obstruction after operation. Twelve patients had a preoperative outflow gradient ≥50 mm Hg (average 86 ± 7) under basal conditions, which decreased to 3 ± 1.8 mm Hg postoperatively (p < 0.001). Nine patients had a severe preoperative gradient only with a provocative maneuver (average 93 ± 6 mm Hg), which decreased to 24 ± 8 mm Hg postoperatively (p < 0.001). Five of the 24 patients undergoing left ventricular myotomy-myectomy incurred an iatrogenic ventricular septal defect. This operative complication occurred primarily in patients with a relatively thin ventricular septum (<20 mm) and contributed importantly to postoperative death in two of the patients.Marked symptomatic and hemodynamic benefit can be achieved in patients requiring operation for obstructive hypertrophic cardiomyopathy and coronary artery disease. Operative mortality was higher than that in patients operated on for either disease alone, in part because of an increased frequency of iatrogenic ventricular septal defect. Consequently, mitral valve replacement may be preferable to left ventricular myotomy-myectomy in some patients with obstructive hypertrophic cardiomyopathy, coronary artery disease and relatively thin ventricular septum.

Discrete Subaortic Stenosis: Assessing Adequacy of Myectomy by Transesophageal Echocardiography

Abstract Background; Membranectomy and myectomy are standard therapy for discrete subaortic stenosis (DS) and are associated with low rates of endocarditis, recurrence, and aortic insufficiency. Extensive myectomy increases risk of complications such as conduction tissue damage and iatrogenic ventricular septal defect (VSD). Materials and Methods: Forty-five adult patients with DS underwent operations in Gulhane Military Medical Academy. Ex-ertional dyspnea was the principal symptom in 29 (64.496) patients. Transesophageal echocardiography (TEE) was performed routinely in all patients to assess the length and depth of needed myectomy during the perioperative period. Aortic insufficiency (AI) was also noted preoperatively in 31 (68·9%) and a history of aortic valve endocarditis was present in 4 (8·9%) patients. Results: Myectomy was performed according to TEE measurements. An average of 10 mm in width, 10 mm in depth, and 2·3 mm in length of septal tissue was resected. The mean left ventricle-aorta peak systolic gradient decreased from 70·2 ± 9·7 to 17·2 ± 2·7 mmHg (p<0·001). Aortic valve repair was performed in 8 (7·8%) patients and aortic valve replacement in 11 (24·4%) patients at the initial operation. Iatrogenic VSD did not occur in any of the patients. Average postoperative left ventricular outflow tract diameter was 21 ± 1·5 mm. Temporary complete heart block occurred in three patients. There was an early residual gradient (36 ± 8 mmHg) resulting from temporary hypercontraction that decreased (18 ± 5 mmHg) in the first postoperative day. Conclusions: Myectomy under perioperative TEE measurement is safe and effective in the treatment of DS. TEE-guided myectomy reduces complications such as complete heart block and iatrogenic VSD.

Aortographic follow-up in patients with the Björk-Shiley aortic disc valve prosthesis.

One hundred aortographic examinations were performed in a follow-up study of 99 long-term survivors after aortic valve replacement with the Bjork-Shiley tilting disc valve. Regurgitation of the contrast medium through the prosthesis as well as paravalvular leakage were evaluated. The regurgitation was minimal (grade I) in 57%, moderate (grade II) in 38%, marked (grade III) in 3% and very marked (grade IV) in 2%. The grade IV cases were re-operated on with closure of paravalvular leakage. The minimal or “functional” regurgitation through the valve prosthesis is an expected finding. It is due to the construction of the Bjork-Shiley valve, whereby the disc fits within its orifice leaving a minimal space between the edge of the disc and the ring. The follow-up aortography showed aneurysms in five patients, deformations of the ascending aorta in three and an iatrogenic ventricular septal defect in one patient.