Comment
Ventricular septal dissection with VSR is an extremely rare complication
following myocardial infarction, and the optimal surgical strategy
remains unclear because of the limited number of cases who have
survived. In ventricular septal dissection, an entry that originates in
the infarcted septal myocardium extends into the ventricular septum as
an intramyocardial dissection.
Only a few cases of ventricular free wall dissection with VSR have been
reported as having been successfully treated (1–3). However,
ventricular septal dissection with VSR that has been treated surgically
has only rarely been reported (4).
In this case, our approach started from the dissected cavity, as
reported in a previous case (3). This approach was chosen to minimize
damage to the non-infarcted myocardium. Additionally, to reliably
prevent residual shunt and maintain cardiac function after surgery, the
VSR was closed, and the dissection was excluded via the modified
extended double patch repair (5). In this approach, the second patch is
easily placed on the side of the dissected cavity side through the
cavity.
With the extended double patch method based on the right ventricular
approach to a VSR caused by myocardial infarction, right heart failure
due to the right ventricular incision may be a problem after surgery
(5). From this perspective, our approach via the dissected cavity can
reasonably be said to be the safer procedure. Furthermore, with the
extended double patch method, the patch is sutured more securely, with
large transseptal/transmural mattress sutures rather than a continuous
suture, minimizing the perioperative risk of shunt recurrence and
securing the closure of the dissected cavity.
For these reasons, we believe this to be an optimal procedure, since the
extended double patch prevents residual shunt more effectively, and also
prevents postoperative RV and LV remodeling. The modified extended
double patch technique with the approach via the dissected cavity to the
septal dissection offers an apparently very secure anchorage plus double
coverage, provides secure closure of the dissected cavity, spares the
contractile area, and facilitates safe glue placement.
In summary, we have reported an extremely rare case of ventricular
septal dissection with VSR, which was treated successfully using a
modification of the extended double patch method.