The Postoperative Paradoxical Septum (POPS): A Comprehensive Review on Physio-Pathological Mechanisms.

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.

The presence of abnormal septal motion on echocardiography is a predictor of abnormal cardiac magnetic resonance in systemic sclerosis.

OBJECTIVES: We aimed to perform a comprehensive analysis of the ECG, two-dimensional echocardiography (2DE) and cardiac MRI (CMR) findings in patients with systemic sclerosis (SSc), and also to investigate correlations between CMR findings and some ECG and echocardiography (ECHO) results. METHODS: We retrospectively analysed data from patients with SSc who were regularly seen at our outpatient referral centre, all assessed with ECG, Doppler ECHO and CMR. RESULTS: Ninety-three patients were included; mean (s.d.) age of 48.5 (10.3) years, 86% female, 52% diffuse SSc. Eighty-four (90%) of the patients had sinus rhythm. The most common ECG finding was the left anterior fascicular block, recorded in 26 patients (28%). The abnormal septal motion (ASM) was found in 43 (46%) patients on ECHO. Myocardial involvement (inflammation or fibrosis), as assessed by multiparametric CMR, was present in >50% of our patients. The age- and sex-adjusted model showed that ASM on ECHO increased significantly the odds of increased extracellular volume [odds ratio (OR) 4.43, 95% CI 1.73, 11.38], increased T1 Relaxation time (OR 2.67, 95% CI 1.09, 6.54), increased T2 Relaxation time (OR 2.56, 95% CI 1.05, 6.22), increased signal intensity ratio in T2-weighted imaging (OR 2.56, 95% CI 1.05, 6.22), presence of late gadolinium enhancement (OR 3.85, 95% CI 1.52, 9.76) and mid-wall fibrosis (OR 3.64, 95% CI 1.48, 8.96). CONCLUSION: This study indicates that the presence of ASM on ECHO is a predictor of abnormal CMR in SSc patients, and a precise assessment of ASM may serve as an important point for selecting the patients that should be evaluated by CMR for early detection of myocardial involvement.

Echocardiographic Patterns of Abnormal Septal Motion: Beyond Myocardial Ischemia.

Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement not only relies on contractile properties but is also affected by the pressure gradient between the 2 ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.

A Potential Echocardiographic Classification for Constrictive Pericarditis Based on Analysis of Abnormal Septal Motion.

BACKGROUND: Constrictive pericarditis is an uncommon condition that could be easily confused with congestive heart failure. In symptomatic patients, septal "wobble" on echocardiography may be an important sign of constrictive physiology. This study was planned to investigate the effects of constriction on septal motion as identified by echocardiography. METHODS: In this retrospective observational study, nine consecutive patients with constriction underwent careful echocardiographic analysis of the interventricular septum (IVS) with slow motion 2-dimensional echocardiography and inspiratory manoeuvres. Six patients who had undergone cardiac magnetic resonance imaging underwent similar analysis. Findings were correlated with haemodynamic data in five patients who had undergone cardiac catheterisation studies. RESULTS: In mild cases of constriction a single wobble of the IVS was seen during normal respiration. In more moderate cases a double motion of the septum (termed "double wobble") was seen where the septum bowed initially into the left ventricle (LV) cavity in diastole then relaxed to the middle only to deviate again into the LV cavity late in diastole after atrial contraction. In severe cases, the septum bowed into the LV cavity for the full duration of diastole (pan-diastolic motion). We describe how inspiration also helped to characterize the severity of constriction especially in mild to moderate cases. CONCLUSION: Echocardiography appears a simple tool to help diagnose constriction and grade its severity. Larger studies are needed to confirm whether the type of wobble motions helps to grade the severity of constrictive pericarditis.

A Potential Echocardiographic Classification for Constrictive Pericarditis Based on Analysis of Abnormal Septal Motion

BACKGROUND: Constrictive pericarditis is an uncommon condition that could be easily confused with congestive heart failure. In symptomatic patients, septal "wobble" on echocardiography may be an important sign of constrictive physiology. This study was planned to investigate the effects of constriction on septal motion as identified by echocardiography. METHODS: In this retrospective observational study, nine consecutive patients with constriction underwent careful echocardiographic analysis of the interventricular septum (IVS) with slow motion 2-dimensional echocardiography and inspiratory manoeuvres. Six patients who had undergone cardiac magnetic resonance imaging underwent similar analysis. Findings were correlated with haemodynamic data in five patients who had undergone cardiac catheterisation studies. RESULTS: In mild cases of constriction a single wobble of the IVS was seen during normal respiration. In more moderate cases a double motion of the septum (termed "double wobble") was seen where the septum bowed initially into the left ventricle (LV) cavity in diastole then relaxed to the middle only to deviate again into the LV cavity late in diastole after atrial contraction. In severe cases, the septum bowed into the LV cavity for the full duration of diastole (pan-diastolic motion). We describe how inspiration also helped to characterize the severity of constriction especially in mild to moderate cases. CONCLUSION: Echocardiography appears a simple tool to help diagnose constriction and grade its severity. Larger studies are needed to confirm whether the type of wobble motions helps to grade the severity of constrictive pericarditis.

Abnormal motion of the interventricular septum after coronary artery bypass graft surgery: comprehensive evaluation with MR imaging.

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.

Abnormal Motion of the Interventricular Septum after Coronary Artery Bypass Graft Surgery: Comprehensive Evaluation with MR Imaging

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.