Unruptured ventricular septal wall dissection. A case report

Dissection of the interventricular septum (IVS) is a rare condition, which can uncommonly complicate an acute myocardial infarction (AMI). We describe a case of unruptured IVS dissection observed 16 days after 2 close episodes of AMI. The diagnosis was made by transthoracic echocardiography. An echo-free space within the thickness of IVS, extended from the apex to the mid-portion, for a total length of about 30 mm was evident. The careful examination of the left ventricle did not reveal any discontinuity of the myocardial wall. The stable clinical condition, the absence of flow within the dissection, the demonstration of its favourable evolution during the hospitalisation and the characteristics of the underlying coronary disease (left anterior descending artery occlusion without myocardial viability) led to the decision of avoiding surgery. The predischarge contrast echocardiographic examination (Levovist) showed clearly the border of the infarcted zone and demonstrated an area reduction and echogenicity increase of the neocavitation, with partially organised thrombi. The patient recovered uneventfully and was discharged on medical therapy with a clinical and echocardiographic follow-up program. We believe that for IVS hemorrhagic dissection a nonsurgical option can be proposed; surgery should only be considered for myocardial revascularization when indicated. A close echocardiographic follow-up is mandatory.