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Di Virgilio E, Basile P, Carella MC, Monitillo F, Santoro D, Latorre MD, D’Alessandro S, Fusini L, Fazzari F, Pontone G, Guaricci AI. The Postoperative Paradoxical Septum (POPS): A Comprehensive Review on Physio-Pathological Mechanisms. J Clin Med 2024; 13:2309. [PMID: 38673582 PMCID: PMC11050797 DOI: 10.3390/jcm13082309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
The interventricular septum (IVS) is a core myocardial structure involved in biventricular coupling and performance. Physiologically, during systole, it moves symmetrically toward the center of the left ventricle (LV) and opposite during diastole. Several pathological conditions produce a reversal or paradoxical septal motion, such as after uncomplicated cardiac surgery (CS). The postoperative paradoxical septum (POPS) was observed in a high rate of cases, representing a unicum in the panorama of paradoxical septa as it does not induce significant ventricular morpho-functional alterations nor negative clinical impact. Although it was previously considered a postoperative event, evidence suggests that it might also appear during surgery and gradually resolve over time. The mechanism behind this phenomenon is still debated. In this article, we will provide a comprehensive review of the various theories generated over the past fifty years to explain its pathological basis. Finally, we will attempt to give a heuristic interpretation of the biventricular postoperative motion pattern based on the switch of the ventricular anchor points.
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Affiliation(s)
| | - Paolo Basile
- University Cardiology Unit, Interdisciplinary Department of Medicine, “Aldo Moro” University School of Medicine, AOUC Polyclinic, 70121 Bari, Italy; (P.B.); (M.C.C.); (F.M.); (D.S.); (M.D.L.)
| | - Maria Cristina Carella
- University Cardiology Unit, Interdisciplinary Department of Medicine, “Aldo Moro” University School of Medicine, AOUC Polyclinic, 70121 Bari, Italy; (P.B.); (M.C.C.); (F.M.); (D.S.); (M.D.L.)
| | - Francesco Monitillo
- University Cardiology Unit, Interdisciplinary Department of Medicine, “Aldo Moro” University School of Medicine, AOUC Polyclinic, 70121 Bari, Italy; (P.B.); (M.C.C.); (F.M.); (D.S.); (M.D.L.)
| | - Daniela Santoro
- University Cardiology Unit, Interdisciplinary Department of Medicine, “Aldo Moro” University School of Medicine, AOUC Polyclinic, 70121 Bari, Italy; (P.B.); (M.C.C.); (F.M.); (D.S.); (M.D.L.)
| | - Michele Davide Latorre
- University Cardiology Unit, Interdisciplinary Department of Medicine, “Aldo Moro” University School of Medicine, AOUC Polyclinic, 70121 Bari, Italy; (P.B.); (M.C.C.); (F.M.); (D.S.); (M.D.L.)
| | | | - Laura Fusini
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (L.F.); (F.F.); (G.P.)
| | - Fabio Fazzari
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (L.F.); (F.F.); (G.P.)
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (L.F.); (F.F.); (G.P.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Interdisciplinary Department of Medicine, “Aldo Moro” University School of Medicine, AOUC Polyclinic, 70121 Bari, Italy; (P.B.); (M.C.C.); (F.M.); (D.S.); (M.D.L.)
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Diviggiano EE, Rosi S, Landra F, Marallo C, Scoppa C, Castellani D, Mandoli GE, Pastore MC, Cavigli L, D’Ascenzi F, Cameli M, Focardi M. Reverse Septal Movement: A Step Forward in the Comprehension of the Underlying Causes. J Clin Med 2024; 13:928. [PMID: 38398242 PMCID: PMC10889416 DOI: 10.3390/jcm13040928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/02/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Reverse septal movement (RSM) often occurs after cardiac surgery, consisting of a paradoxical systolic movement of the interventricular septum. In this retrospective study, we aimed to investigate possible determinants of RSM after coronary artery bypass surgery (CABG). (2) Methods: Patients who underwent CABG with on- or off-pump techniques at our center from March 2019 to October 2021 were retrospectively included. Exclusion criteria were: exposure to combined procedures (e.g., valve implantation), prior cardiac surgery, intraventricular conduction delays, and previous pacemaker implantation. Laboratory tests and echocardiographic and cardiopulmonary bypass (CPB) duration data were collected. (3) Results: We enrolled 138 patients, of whom 32 (23.2%) underwent off-pump CABG. Approximately 89.1% of the population was male; the mean age was 70 ± 11 years. There was no difference in RSM incidence in patients undergoing the off-pump and on-pump techniques (71.9% vs. 62.3%; p = 0.319). In patients undergoing on-pump surgery, the incidence of RSM was slightly higher in longer CPB procedures (OR 1.02 (1.00-1.03) p = 0.012), and clamping aortic time was also greater (OR 1.02 (1.00-1.03) p = 0.042). (4) Conclusions: CPB length seems to be correlated with a higher RSM appearance. This better knowledge of RSM reinforces the safety of CABG and its neutral effect on global biventricular function.
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Affiliation(s)
- Enrico Emilio Diviggiano
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Sara Rosi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Federico Landra
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Carmine Marallo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Cristina Scoppa
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (C.S.); (D.C.)
| | - Debora Castellani
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (C.S.); (D.C.)
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Flavio D’Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (S.R.); (F.L.); (C.M.); (G.E.M.); (M.C.P.); (L.C.); (F.D.); (M.C.); (M.F.)
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Kang MK, Chang HJ, Cho IJ, Shin S, Shim CY, Hong GR, Yu KJ, Chang BC, Chung N. Echocardiographic investigation of the mechanism underlying abnormal interventricular septal motion after open heart surgery. J Cardiovasc Ultrasound 2014; 22:8-13. [PMID: 24753803 PMCID: PMC3992352 DOI: 10.4250/jcu.2014.22.1.8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 03/12/2014] [Accepted: 03/12/2014] [Indexed: 11/22/2022] Open
Abstract
Background Abnormal interventricular septal motion (ASM) is frequently observed after open heart surgery (OHS). The aim of this study was to investigate the incidence and temporal change of ASM, and its underlying mechanism in patients who underwent OHS using transthoracic echocardiography (TTE). Methods In total, 165 patients [60 ± 13 years, 92 (56%) men] who underwent coronary bypass surgery or heart valve surgery were consecutively enrolled in a prospective manner. TTE was performed preoperatively, at 3--6-month postoperatively, and at the 1-year follow-up visit. Routine TTE images and strain analysis were performed using velocity vector imaging. Results ASM was documented in 121 of 165 patients (73%) immediately after surgery: 26 patients (17%) presented concomitant expiratory diastolic flow reversal of the hepatic vein, 11 (7%) had inferior vena cava plethora, and 11 (7%) had both. Only 2 patients (1%) showed clinically discernible constriction. ASM persisted 3--6 months after surgery in 38 patients (25%), but only in 23 (15%) after 1 year. There was no difference in preoperative and postoperative peak systolic strain of all segments of the left ventricle (LV) between groups with or without ASM. However, systolic radial velocity (VRad) of the mid anterior-septum and anterior wall of the LV significantly decreased in patients with ASM. Conclusion Although ASM was common (74%) immediately after OHS, it disappeared over time without causing clinically detectable constriction. Furthermore, we consider that ASM might not be caused by myocardial ischemia, but by the decreased systolic VRad of the interventricular septum after pericardium incision.
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Affiliation(s)
- Min-Kyung Kang
- Cardiology Division, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea. ; Severance Biomedical Science Institute, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - In Jeong Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Sanghoon Shin
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Chi-Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Kyung-Jong Yu
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Byung-Chul Chang
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Namsik Chung
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
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Choi SH, Choi SI, Chun EJ, Chang HJ, Park KH, Lim C, Kim SJ, Kang JW, Lim TH. Abnormal motion of the interventricular septum after coronary artery bypass graft surgery: comprehensive evaluation with MR imaging. Korean J Radiol 2010; 11:627-31. [PMID: 21076588 PMCID: PMC2974224 DOI: 10.3348/kjr.2010.11.6.627] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 07/22/2010] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To define the mechanism associated with abnormal septal motion (ASM) after coronary artery bypass graft surgery (CABG) using comprehensive MR imaging techniques. MATERIALS AND METHODS Eighteen patients (mean age, 58 ± 12 years; 15 males) were studied with comprehensive MR imaging using rest/stress perfusion, rest cine, and delayed enhancement (DE)-MR techniques before and after CABG. Myocardial tagging was also performed following CABG. Septal wall motion was compared in the ASM and non-ASM groups. Preoperative and postoperative results with regard to septal wall motion in the ASM group were also compared. We then analyzed circumferential strain after CABG in both the septal and lateral walls in the ASM group. RESULTS All patients had normal septal wall motion and perfusion without evidence of non-viable myocardium prior to surgery. Postoperatively, ASM at rest and/or stress state was documented in 10 patients (56%). However, all of these had normal rest/stress perfusion and DE findings at the septum. Septal wall motion after CABG in the ASM group was significantly lower than that in the non-ASM group (2.1±5.3 mm vs. 14.9±4.7 mm in the non-ASM group; p < 0.001). In the ASM group, the degree of septal wall motion showed a significant decrease after CABG (preoperative vs. postoperative = 15.8±4.5 mm vs. 2.1±5.3 mm; p = 0.007). In the ASM group after CABG, circumferential shortening of the septum was even larger than that of the lateral wall (-20.89±5.41 vs. -15.41±3.7, p < 0.05) CONCLUSION Abnormal septal motion might not be caused by ischemic insult. We suggest that ASM might occur due to an increase in anterior cardiac mobility after incision of the pericardium.
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Affiliation(s)
- Seong Hoon Choi
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Maslow A, Schwartz C, Mahmood F, Singh A, Heerdt PM. Case report: paradoxical ventricular septal motion in the setting of primary right ventricular myocardial failure. Can J Anaesth 2009; 56:510-7. [PMID: 19475470 DOI: 10.1007/s12630-009-9108-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Revised: 03/30/2009] [Accepted: 04/06/2009] [Indexed: 11/24/2022] Open
Abstract
PURPOSE In this report, a case of right ventricular (RV) failure, hemodynamic instability, and systemic organ failure is described to highlight how paradoxical ventricular systolic septal motion (PVSM), or a rightward systolic displacement of the interventricular septum, may contribute to RV ejection. CLINICAL FEATURES Multiple inotropic medications and vasopressors were administered to treat right heart failure and systemic hypotension in a patient following combined aortic and mitral valve replacement. In the early postoperative period, echocardiographic evaluation revealed adequate left ventricular systolic function, akinesis of the RV myocardial tissues, and PVSM. In the presence of PVSM, RV fractional area of contraction was > or =35% despite akinesis of the primary RV myocardial walls. The PVSM appeared to contribute toward RV ejection. As a result, the need for multiple inotropes was re-evaluated, in considering that end-organ dysfunction was the result of systemic hypotension and prolonged vasopressor administration. After discontinuation of phosphodiesterase inhibitors, native vascular tone returned and the need for vasopressors declined. This was followed by recovery of systemic organ function. Echocardiographic re-evaluation two years later, revealed persistent akinesis of the RV myocardial tissues and PVSM, the latter appearing to contribute toward RV ejection. CONCLUSIONS This case highlights the importance of left to RV interactions, and how PVSM may mediate these hemodynamic interactions.
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Affiliation(s)
- Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, USA.
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Joshi SB, Salah AK, Mendoza DD, Goldstein SA, Fuisz AR, Lindsay J. Mechanism of paradoxical ventricular septal motion after coronary artery bypass grafting. Am J Cardiol 2009; 103:212-5. [PMID: 19121438 DOI: 10.1016/j.amjcard.2008.08.067] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 08/28/2008] [Accepted: 08/28/2008] [Indexed: 10/21/2022]
Abstract
Paradoxical septal motion is commonly noted on echocardiography after coronary artery bypass grafting (CABG), but its mechanism is unclear. Cardiac magnetic resonance imaging was performed before and 3 months after CABG in 23 patients. On a mid-left ventricular short-axis cine image, the motion of myocardial landmarks during the cardiac cycle was ascertained relative to a stationary anterior reference point. Before CABG, the movement of the ventricular septum in systole was either posterior or neutral (median -2 mm) in 19 patients, whereas after CABG, the septum moved anteriorly in all 23 patients (+4 mm; p<0.001). (A positive sign indicates anterior motion in ventricular systole, and a negative sign denotes posterior motion.) The motion of the right ventricular free wall was reduced after CABG (-5 vs -3 mm; p=0.002), whereas anterior movement of the lateral left ventricular wall in systole increased (+4 vs +9 mm; p<0.001). There was a positive correlation between degree of anterior movement of the ventricular septum and right ventricular ejection fraction (r=0.47, p=0.023). In conclusion, after CABG, the entire left ventricle translocated anteriorly in systole. Despite preserved right ventricular function, there was restricted motion of the right ventricular free wall suggestive of postoperative adhesions. The pattern of movement observed offers a sound explanation for postoperative paradoxical septal motion.
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Rott D, Feinberg MS, Agranat O, Kaplinsky E, Rabinowitz B, Schwammenthal E. Effect of inotropic stimulation on motion and thickening of the ventricular septum following either coronary artery bypass grafting or mitral valve replacement for mitral stenosis. Am J Cardiol 2001; 88:1040-3. [PMID: 11704007 DOI: 10.1016/s0002-9149(01)01988-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- D Rott
- Heart Institute, Sheba Medical Center, Tel Hashomer, Israel
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Germano G, Erel J, Lewin H, Kavanagh PB, Berman DS. Automatic quantitation of regional myocardial wall motion and thickening from gated technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography. J Am Coll Cardiol 1997; 30:1360-7. [PMID: 9350940 DOI: 10.1016/s0735-1097(97)00276-3] [Citation(s) in RCA: 209] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We developed an automatic quantitative algorithm for the measurement of regional myocardial wall motion and wall thickening from three-dimensional gated technetium-99m sestamibi myocardial perfusion single-photon emission computed tomographic images. BACKGROUND The algorithm measures the motion of the three-dimensional endocardial surface using a modification of the centerline method, as well as wall thickening using both geometry (gaussian fit) and partial volume (counts). METHODS The algorithm was tested using a "variable thickness" heart phantom, and the quantitative results were compared with visual segmental assessment of myocardial motion and thickening in 79 clinical patients with a wide range of ejection fractions (6% to 87%). RESULTS Phantom measurements of simulated motion and thickening were accurate regardless of the camera used (dual or triple detector), the angular span of reconstructed data (180 degrees or 360 degrees), the amount of motion (3 or 6 mm) or the amount of thickening (33%, 50% or 100%). Quantitative measurements of segmental motion and thickening in the patients were correlated with visual scores (r = 0.668, exact agreement 72.6%, kappa 0.433 and r = 0.550, exact agreement 74.7%, kappa 0.408, respectively). Significant inverse linear relations exist between the global (summed) visual motion score and the average quantitative motion, and between the global (summed) visual thickening score and the average quantitative thickening. Automatic quantitative ejection fraction measurements correlated extremely well with average quantitative motion (r = 0.929) and thickening (r = 0.959). CONCLUSIONS Our algorithm is accurate and may be the first automatic technique for the quantitative three-dimensional assessment of regional ventricular function in cardiology.
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Affiliation(s)
- G Germano
- Department of Medicine, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, University of California Los Angeles School of Medicine, 90048, USA.
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