Discussion
Intramyocardial dissection is rare and mostly secondary to myocardial
infarction.In a meta-analysis2 of the literature
including 40 cases of Intramyocardial dissection,32 cases after
myocardial infarction and in 8 patients following trauma.3-4 In 5 patients, communication between the left and
right ventricles was found. In-hospital mortality was 23%. Multivariate
analysis showed that the strongest independent predictor of mortality
was EF<35%.2 There also were a few reports
of intramyocardial dissection secondary to the cardiac
echinococcosis.5-6 Intramyocardial dissection
following cardiac tumor excision is uncommon,the evidence available is
limited to few case reports. This complication is due to destruction of
the integrity of the interventricular septum and entry into the
ventricular cavities during resection of the tumor. In our patient, only
very thin endocardium separated the tumor from the ventricular cavity,
entering into the left ventricular cavity when the tumor was
dissected.we repaired the septum with a bovine pericardium patch. It may
be due to the fragility of the myocardial tissue leading to the suture
avulsion, followed by the formation of ventricular septal
intramyocardial dissection and
residual shunt.
The optimal management of intramyocardial dissection is controversial
due to its rarity and lack of supportive evidence. Most of the
experience come from studies of intramyocardial dissection after
myocardial infarction. Treatment includes surgery, intervention and
conservative medical therapy. In a systematic review of patients with
postinfarction intramyocardial dissection, the mortality rate was
significantly higher in the medical group versus surgical-treated group
(85.7% versus 42.3%).7 For our patient, the age was
only 3 months, interventional treatment was difficult, and the risk of
reoperation was high. Most importantly, the patient was asymptomatic and
hemodynamically stable.So we performed conservative strategy. During
follow-up, we found that the cystic dissection was slightly reduced and
the shunts between the cystic dissection and right ventricle
disappeared. We will continue to follow up the patient.
Echocardiography is a noninvasive and simple technique.It has a
important role in diagnosing intramyocardial dissection.
Echocardiography
can evaluate the size and location of the intramyocardial dissection,
detect flow within the cavity,assess heart function, thus assisting in
the decisions about treatment strategy.We can learn from our case that
when resecting tumors located in the ventricular septum, we should try
to ensure the integrity of the ventricular septum and avoid entering the
ventricular cavity. After resection, we should carefully check and
repair the ventricular septum. For benign cardiac tumors can be partial
resection to prevent damage to important structures.8