CASE REPORTS   

Chirurgia 2015 June;28(3):123-4

Copyright © 2015 EDIZIONI MINERVA MEDICA

language: English

Concealed ventricular septal defects revealed after surgical repair of a double-chambered right ventricle in an adult

Fukaya S., Koyama Y., Kitamura H., Komeda M.

Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Japan

We report the case of a 69-year-old man who underwent successful surgery for double-chambered right ventricle with a pressure gradient of 109 mmHg, but showed two small “hidden” ventricular septal defects (VSD) postoperatively. He was referred to our hospital with worsening exertional dyspnea. Echocardiography showed extreme hypertrophy of the RV (maximum diameter, 17.6 mm) and subpulmonary RV outflow tract (RVOT) stenosis caused by an anomalous muscle bundle. No other anomalies, including VSD, were identified at this time. Cardiac catheterization demonstrated a pressure gradient of 109 mmHg between the RV apex and subpulmonary region. Open-heart surgery was subsequently performed. The RVOT was opened and the fibrous anomalous RV muscle bundle was resected. Scarring from a closed type I VSD was found. The RVOT was reconstructed using a Gore-Tex patch. Cardiac catheterization revealed no pressure gradient but two small VSDs (types I and II). Qp/Qs was 1.33. We were unable to detect the VSDs pre- or intraoperatively, in part because these VSDs were small and located in the high-pressure proximal RV. VSDs might have no shunt flow and became scars, because left ventricular pressure and RV pressure are almost equal. We successfully released RVOT stenosis and completely eliminated the pressure gradient by making best exposure using incisions of the pulmonary artery (PA), right atrium (RA), and RVOT. Even so, VSDs remained present. Care is required to detect VSDs intraoperatively, and employing modalities such as direct surface echo may prove helpful.