Postoperative Dissecting Ventricular Septal Hematoma: Recognition and Treatment

Dissecting ventricular septal hematoma (DVSH) rarely occurs after repair of a ventricular septal defect (VSD) but can lead to serious complications such as septal rupture, myocardial rupture, cardiogenic shock, heart block, outflow obstruction, cardiac tamponade, abscess transformation, and death. This paper describes the diagnosis and management of acute, severe, left ventricular outflow tract obstruction caused by the development of a DVSH after VSD repair. 1. Introduction Dissecting ventricular septal hematoma (DVSH) after repair of ventricular septal defect (VSD) is a rare [1], potentially life threatening [2, 3] complication initiated by surgical disruption of the coronary microcirculation. The resultant bleeding dissects along a plane beneath the endocardium resulting in a hematoma that bulges out into ventricular cavity. The following is a case report of the diagnosis and management of acute, severe, left ventricular outflow tract (LVOT) obstruction caused by the development of a DVSH after VSD repair. 2. Case Presentation A 7-week-old male infant was noted to be hypoxemic prior to repair of an inguinal hernia. A postoperative echocardiogram demonstrated a large membranous VSD and a long segment coarctation of the aorta. Three months after repair of the coarctation the infant was in congestive heart failure and was brought to the operating room for VSD repair. Preoperative transesophageal echocardiography (TEE) demonstrated a large membranous VSD that extended into the inlet septum and a widely patent left ventricular outflow tract (Figure 1). Figure 1: Intraoperative TEE demonstrating a patent LVOT (unlabeled arrow) and the large membranous VSD. Key: LVOT—left ventricular outflow tract, TEE—transesophageal echocardiogram, VSD—ventricular septal defect. VSD repair was performed using aortobicaval cannulation with mild hypothermia and antegrade cardioplegeic arrest. The echocardiographic findings were confirmed at surgery, and the VSD was closed in the standard manner using a Dacron patch and 5–0 Prolene pledgeted suture. The initial suture line was carried clockwise avoiding the crest of the ventricular septum. Near the septal leaflet of the tricuspid valve, sutures were placed superficially to avoid the conduction system. The VSD was then closed in a counterclockwise fashion staying away from the crest of the ventricular septum, across the ventricular infundibular fold avoiding the aortic annulus, and eventually transitioning to the septal leaflet of the tricuspid valve. The remainder of the VSD underneath the septal leaflet of the tricuspid