Mechanism of paradoxical ventricular septal motion after coronary artery bypass grafting

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.