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Extracorporeal membrane oxygenation as a novel management strategy for interventricular septal hematoma following ventricular septal defect repair

  • Anusha Jegatheeswaran
    Correspondence
    Address for reprints: Anusha Jegatheeswaran, MD, PhD, Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8 Canada.
    Affiliations
    Division of Cardiac Surgery, Department of Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada

    Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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  • Meryl S. Cohen
    Affiliations
    Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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  • J. William Gaynor
    Affiliations
    Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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  • Christopher E. Mascio
    Affiliations
    Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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  • Thomas L. Spray
    Affiliations
    Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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  • Stephanie Fuller
    Affiliations
    Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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Published:October 16, 2019DOI:https://doi.org/10.1016/j.jtcvs.2019.09.150

      Abstract

      Objectives

      Interventricular septal hematoma (IVSH) is a rare complication, which may result from ventricular septal defect (VSD) repair. IVSH can result in conduction and/or hemodynamic abnormalities related to impaired ventricular filling or outflow tract obstruction. We report the novel use of extracorporeal membrane oxygenation (ECMO) for management.

      Methods

      Echocardiography reports (January 1980 to December 2016) were searched for the term “hematoma” in our institutional database and reviewed to determine appropriate cases. Charts and imaging (reports) data were abstracted. All intraoperative and select postoperative echocardiograms were reread by a pediatric cardiologist.

      Results

      N = 12 patients with IVSH. Mean age and weight at surgery were 59 ± 41 days and 3.4 (2.9-5.1) kg, respectively, while the most frequent diagnosis was tetralogy of Fallot. Although all patients had intraoperative transesophageal echocardiography (TEE), only 55% (6 of 11, missing [m] = 1) of IVSH were discovered intraoperatively. Of the 5 patients not discovered intraoperatively (m = 1), IVSH was postoperatively detected secondary to arrhythmia/decompensation by echocardiogram 10.1 ± 7.9 hours postoperatively. Five patients (42%) were managed with ECMO (1 unable to separate from bypass). Overall mortality was 33%. For patients in whom ECMO was used, 2 of 5 (40%) survived. Mean time to IVSH resolution in all survivors was 20 ± 185 days.

      Conclusions

      IVSH from VSD repair can result in clinical decompensation and mortality. This may relate to the high proportion missed intraoperatively. ECMO should be considered an important modality, which can allow for IVSH resolution. However, considerations must be made to allow for appropriate anticoagulation to avoid hematoma expansion and repeat imaging during ECMO to continually assess the interventricular septum.

      Key Words

      Abbreviations and Acronyms:

      ECMO (extracorporeal membrane oxygenation), IVSH (interventricular septal hematoma), TEE (transesophageal echocardiography), VSD (ventricular septal defect)
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