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AMA PRA Category 1 Credit(s)TM for Physicians Only.
ASRT CME Not Available
Case-of-the-Week Information
The Case-of-the-Month is a presentation of one 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).

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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE before Operation
IntraopPostOp Intraop TEE after Operation
IntraopEnd Intraop TEE 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
CME Requirements: Active CME Session and must be a paid, active subscriber to iTEE or advanced TEE AND have enough CME credits in your bank. AMA CME ONLY.
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?

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.
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