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.