Defaults: 1X 2X 3X 4X      
Case of the Week
UNMC Advertisement
 Go to the COTW Archive
 
Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

You can change the size and the format of the image or video loops by using the links below the image or video loop.
= Windows Media Video = MP4 Video
= QuickTime = WebM Video
= Flash = Ogg Video
= JPG Image = GIF Image
Video Sizes  
1X = 200x150 pixels
2X = 400x300 pixels
3X = 600x450 pixels
4X = 800x600 pixels
Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Myectomy Complication
Case#: 38
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
Presentation:
79 yo male with history of Hypertrophic Cardiomyopathy (HCM) and Systolic Anterior Motion (SAM) of the mitral valve with severe subaortic obstruction underwent a septal myectomy. In the ICU the patient became unstable.

Please review the TEE and give your assessment.
Please consider the following questions:

What are complications from a septal myectomy?
What is the diagnosis?
What is the severity of the diagnosis?
What are the therapeutic options for the diagnosis?

 
Loops:


Case Discussion/CME Questions
 
Complications after a septal myectomy are less than 1%. Complications that can occur are:

  • VSD
  • Complete Heart Block
  • Aortic Regurgitation
  • Coronary Artery Fistula
  • Residual Subaortic Stenosis

A VSD and complete heart block can occur from a too deep myectomy into the septal wall. The aortic regurgitation tends to occur because of destabilization of the aortic annulus by
beginning the myectomy to close to the right coronary cusp. A coronary artery fistula into the right ventricle has been reported. Residual stenosis can occur in an too small excision
of the septal wall or if the mitral valve has persistent SAM despite an adequate resection.


The diagnosis is a ventricular septal defect.
The VSD measured 0.88 cm in diameter with a PISA of 0.68 cm and a Va of 57.8 cm/sec.
The VTI of the VSD was 103 cm. The shunt volume was about 40 mls per cardiac cycle.
The VSD when from the left ventricle to the right ventricle and the right atrium. The RV is dilated and exhibited decreased function.

The therapeutic options are to close the VSD by percutaneous device or by patching the VSD surgically.

A VSD after a septal myectomy is rare but represents a serious complication. Along with a VSD, complete heart block may also occur, especially, if the patient had a failed alcohol ablation of the septum. Another possible complication is a coronary fistula. A case report of an LAD to RV fistula was reported. Closure with a device has been successfully reported in many patients. The technical difficultly of a device closure depend upon the location of the VSD, the size, shape, number of orifices, and orientation of the VSD, and the severity of the VSD. Large, irregular, muscular, and multiorifice VSDs are difficult to close with a device. Small, membranous, single orifice VSDs have the best success rate.

The later videos show a patch repair that later exhibited dehiscence and had to be re-repaired.
Please answer the following questions correctly to obtain your CME.
CME Activites require a subscription and CME credits. Please purchase a subscription and CME credits.
 
 
 
 
 
 
 
 
Instution Info  
User Info  
CME Info  
Help  
User License  
HIPAA  
Privacy Policy  
References   
Calcs   
 
CME Sponsor: University of Nebraska Medical Center - Center for Continuing Education This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of University of Nebraska Medical Center, Center for Continuing Education and JLS Interactive, LLC.
The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CE Sponsor: American Society of Radiological Technologists (ASRT)This activity is approved by the American Society of Radiologic Technologists (ASRT) as sonography-related continuing education (CE). Credit(s) issued for successful completion of ASRT-approved CE activities are accepted by the American Registry of Diagnostic Medical Sonography, American Registry of Radiological Technologists, Cardiovascular Credentialing International and Canadian Association of Registered Diagnostic Ultrasound Professionals. Contact the applicable registry for additional information / restrictions on their acceptance of ASRT CE credit.
Copyright Statement
© Copyright 2000-2019 JLS Interactive, LLC.
Content from this web site may not be used or reproduced for non-personal or
commercial purposes without express written permission by JLS Interactive, LLC.