Case-of-the-Week

Case of the Week

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AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.

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.

Web Links/References

Closure of Ventricular Septal Defect After Surgical Septal Myectomy by Hybrid Procedure in an Adult Patient
A new technique to avoid the intraoperative complications of septal myectomy in patients with obstructive hypertrophic cardiomyopathy
A successful percutaneous closure of ventricular septal defect following septal myectomy in patients with hypertrophic obstructive cardiomyopathy.
Outcome of surgical myectomy after unsuccessful alcohol septal ablation for the treatment of patients with hypertrophic obstructive cardiomyopathy.
[Coronary fistula of the right ventricular outflow tract as a complication of combined transaortic-trans-right ventricular myectomy in hypertrophic obstructive cardiomyopathy]

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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.

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.