Cardiac trauma

Survival following blunt traumatic right ventricular free wall rupture

We present a case of survival after ventricular wall rupture in a young man following a fall. The patient had a delayed presentation to the emergency department with normotension and a slight tachycardia. His complaints were mild dyspnea with thoracic pain. Computed tomography of his chest revealed a pericardial effusion, a right ventricular wall defect with pseudoaneurysm and active contrast extravasation. He was transferred to our tertiary care institution for emergent cardiac intervention. The patient had a unique past surgical history significant for previous median sternotomy as a child for repair of a patent foramen ovale at the age of 13 years. Upon arrival to our facility, the patient underwent surgical exploration, and a transmural defect was identified in the right ventricle. This was repaired on cardiopulmonary bypass, and the patient recovered well. Cardiac injury following blunt thoracic trauma should always be considered when a patient presents with hypotension and tachycardia. Expeditious diagnosis and intervention is required for salvage. We believe our patient’s past surgical history with previous pericardiotomy directly contributed to his survival of a typically lethal injury.

Cardiac Contusion with Early Ventricular Rupture—A Case Report

Myocardial contusion is a common concomitant of high-speed deceleration injuries in our modern society. Despite increasing awareness of this entity among health care professionals, in many cases the diagnosis remains a difficult one to make because of a scarcity of physical signs. The diagnosis is, however, extremely important because of the possible complications, which include low cardiac output state, conduction defects, atrial and ventricular dysrhythmias, and, rarely, even cardiac rupture. Much less common, but also clinically impor tant, is rupture of the free cardiac wall from blunt trauma.

A case of cardiac contusion caused by blunt trauma sustained in a motor vehicle accident complicated by early ventricular rupture is presented. Ten hours after arrival at the hospital, this patient abruptly became hypotensive and sustained a cardiopulmonary arrest, which did not respond to the usual medical measures. Upon open thoracotomy the patient was found to have suffered a right ventricular rupture, which was repaired; however, the patient subse quently expired.

Isolated tear in left atrial appendage due to blunt trauma chest: A rare case report

Blunt traumatic cardiac rupture is associated with a high mortality rate. Motor vehicle accidents account for most cardiac ruptures, but crush injury is relatively rare. We describe a case of a 72-year-old man who had the left atrial appendage ruptured through blunt trauma due to a fall from scooter. Simple suture repair of the atrial appendage was achieved after clamping the base of the left atrium to control the bleeding. He recovered without complication. Traumatic injury to left atrial appendage is rarely seen and reported.

Nail gun may cause heart injury: a young adult's misadventure

Penetrating cardiac and great vessels trauma is life threatening and a surgical challenge. We relate an unusual case of pulmonary artery injury secondary to an accidental trauma by a nail gun. Surgical repair was late but successful.

Chronic mitral regurgitation secondary to a perivalvular leak from remote trauma

We report a rare case of mitral regurgitation as a result of perivalvular leak in a 49-year-old man with a history of blunt trauma. He presented with a 2-month history of progressive exertional dyspnea, angina, and heart failure. Preoperative transesophageal echocardiography demonstrated severe mitral regurgitation as a result of a perivalvular leak of the mitral valve that was not evident on transthoracic echocardiography and cardiac catheterization.

Rupture of Left Atrial Appendage and Pericardium Due to Blunt Trauma

A 37-year-old woman sustained a ruptured pericardium and two lacerations of the left atrial appendage in an automobile accident. Simple suture repair of the atrial appendage was achieved after clamping the base of the left atrium to control the bleeding.

Rupture of mitral chorda tendinea following blunt chest trauma

Acute mitral insufficiency, originated from rupture of mitral chordae tendineae secondary to nonpenetrating thoracic trauma, is an unusual condition. This diagnosis is difficult to establish because physical examination, electrocardiogram, and cardiac enzymes are neither sensitive nor specific. The diagnosis of rupture must be quickly established because this disorder may be fatal. This paper reports the case of a patient with acute mitral insufficiency secondary to a mitral valve chord rupture a week after a nonpenetrating thoracic trauma.

Blunt cardiac injuries in children: a postmortem study

We reviewed the records of the Chief Coroner for all pediatric (< 16 years of age) trauma fatalities in Ontario (pediatric population of 2 million) for the period January 1, 1988 through December 31, 1990. Forty-one (14.5%) of 282 patients for which complete autopsy data were available had sustained cardiac injuries. Nineteen patients (46%) died at the scene of the accident, 15 patients (37%) died in an emergency department, and seven patients (17%) died during hospitalization. Rupture of a cardiac chamber occurred in 16 cases; it was the main cause of death in eight cases and a contributing factor in the remainder. Cardiac contusion without chamber rupture was present in 25 cases, but in none of the cases was it the cause of death. Brain injury was the cause of death in 16 (64%) of the cases of cardiac contusion. Cardiac injuries are more common among children who die from blunt trauma than previous reports have suggested. However, because these injuries are often rapidly fatal, many patients die before they reach a hospital. With improvements in emergency medical services and the resulting reduction in transit time, more patients may reach trauma centers alive. A high index of suspicion and rapid diagnosis and treatment of these injuries can save the lives of some of these patients.

Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion

BACKGROUND

Myocardial contusion is commonly diagnosed following blunt chest trauma, and has potentially lethal complications. Cost-effective case management in patients with suspected myocardial contusion is confounded by the low incidence of complications and the lack of a reliable test to predict them. The clinical usefulness of elevated cardiac enzyme levels is controversial.

METHODS

We analyzed a 4-year experience of 359 patients with high-risk blunt chest trauma who were assessed using an established practice guideline. Our multivariate statistical model evaluated all of the early risk factors included in the guideline, specifically focusing on cardiac enzyme levels.

RESULTS

Myocardial contusion was diagnosed in 30% of patients, and complications (dysrhythmias and cardiogenic shock) occurred in 5%. In no case was cardiac enzyme elevation the sole predictor of a complication. The cost of routine cardiac enzyme assay was substantial.

CONCLUSION

Cardiac enzyme determinations have no useful role in the evaluation of patients with suspected myocardial contusion. They should be eliminated from current practice guidelines.

Subxiphoid pericardial window in the diagnosis of penetrating cardiac trauma

During a 15-month period, a subxiphoid pericardial window was performed as a diagnostic method to rule out cardiac injury in 76 patients with penetrating wounds near the heart. Patients with an obvious diagnosis of cardiac tamponade or patients in severe shock were excluded. Seventy-four patients were male, and 2 were female. The average age was 26.7 years. The procedure was done under general anesthesia in every case. There were no false-positive or false-negative results. There were no deaths, and the morbidity rate was 1.3%. In 16 patients (21%), the procedure identified hemopericardium. In our hands, the subxiphoid pericardial window has proved to be a rapid, precise, and safe method for the diagnosis of wounds of the heart. Until a less invasive procedure proves more precise, we recommend it as the standard diagnostic approach for cardiac injuries in patients in stable condition.

Diagnosis, Management, and Complications of Nonpenetrating Cardiac Trauma: A Perspective for Practicing Clinicians

We provide a state-of-the-art review for practicing clincians concerning diagnosis and treatment of patients with non-penetrating cardiac trauma. Internists, cardiologists, and intensivists are becoming increasingly involved in the diagnosis and management of patients with nonpenetrating cardiac injuries. Electrocardiography and cardiac isoenzyme determinations are the least expensive and most common laboratory tests used to diagnose this condition. Despite widespread use, however, these tests have significant limitations in diagnostic sensitivity and specificy. Two-dimensional echocardiography is advocated by some to improve diagnostic accuracy and to identify patients at increased risk of cardiovascular complications. Patients identified as low risk may be suitable for limited monitoring and early hospital discharge. Transesophageal echocardiography is a useful diagnostic tool that offers many advantages over standard transthoracic imaging. Nuclear medicine techniques, including radionuclide-labeled antimyosin scanning, also represent exciting new developments in this area. Invasive techniques such as cardiac catheterization and pumonary artery catheterization should be reserved for patients with hemodynamic instability and overt mechanical complications. Appropriate selection of diagnostic tests can assist clinicians in rapid traging of patients with nonpenetrating cardiac trauma. Identification of patients at low risk for cardiovascular complications may lead to more appropriate use of hospital resources.

Traumatic ventricular septal defect: serial follow-up with Doppler ultrasound

A three-year-old girl presented with a gunshot wound of the chest. Cross-sectional and Doppler echocardiography enabled precise location of the bullet, and assessment of the haemodynamic effects of the traumatic ventricular septal defect. Serial ultrasound examination in the acute stage confirmed that the bullet was well embedded in the left ventricular myocardium, and the ventricular septal defect was restrictive, enabling conservative management.

[Post-traumatic constrictive pericarditis with fast course]

A case is reported of a 46-year-old male patient who sustained a blunt thoracic injury with an anterior flail chest, and right haemopneumothorax. He was intubated and ventilated because of acute respiratory failure. There were initially no signs suggesting any myocardial injury. It was not before day 20 that the electrocardiogram showed a QS wave in leads V2 and V3. The hypothesis of an antero-septal myocardial infarct was not confirmed by echocardiography, which only revealed slight thickening of the posterior pericardium. From day 50 on, the patient had tachycardia, raised jugular venous pressure, and effort dyspnoea. Echocardiography (day 59) showed an anterior and posterior pericardial effusion (about 500 ml), marked pericardial thickening, and inferior vena caval collapse during inspiration, with normal myocardial wall movements. Drainage pericardiocentesis was therefore carried out, followed by, four days later, a pericardiectomy. A small ecchymosis was found on the anterior aspect of the right ventricle. The pericardium was thickened, fibrous, hyperhaemic, Case is y stuck to the epicardium. Eight months later, echocardiography showed that the posterior pericardium remained thickened, and there was a very small residual effusion. Movements of the septum had returned to normal.

Blunt traumatic cardiac rupture. A 5-year experience

Blunt traumatic cardiac rupture is associated with a high rate of mortality. A review of the computerized trauma registry (1983 to 1988) identified 32 patients with this injury (ages 19 to 65 years; mean age, 39.5 years; 21 men and 11 women). Twenty-one patients (65.6%) were injured in vehicular crashes, 3 (9.4%) in pedestrian accidents, 3 (9.4%) in motorcycle accidents; 3 (9.4%) sustained crush injury; 1 (3.1%) was injured by a fall; and 1 (3.1%) was kicked in the chest by a horse. Anatomic injuries included right atrial rupture (13[40.6%]), left atrial rupture (8 [25%]), right ventricular rupture (10[31.3%]), left ventricular rupture (4[12.5%]), and rupture of two cardiac chambers (3 [9.4%]). Diagnosis was made by thoracotomy in all 20 patients presenting in cardiac arrest. In the remaining 12 patients, the diagnosis was established in seven by emergency left anterolateral thoracotomy and in five by subxyphoid pericardial window. Seven of these 12 patients (58.3%) had clinical cardiac tamponade and significant upper torso cyanosis. The mean Injury Severity Score (ISS), Trauma Score (TS), and Glasgow Coma Scale (GCS) score were 33.8, 13.2, and 14.3, respectively, among survivors and 51.5, 8.3, and 7.0 for nonsurvivors. The overall mortality rate was 81.3% (26 of 32 patients), the only survivors being those presenting with vital signs (6 of 12 patients [50%]). All patients with rupture of two cardiac chambers or with ventricular rupture died. The mortality rate from myocardial rupture is very high. Rapid prehospital transportation, a high index of suspicion, and prompt surgical intervention contribute to survival in these patients.

Colour Doppler flow mapping in the diagnosis of traumatic ventricular septal defect

The use of colour Doppler flow mapping allows noninvasive diagnosis and gives haemodynamic information on the severity of ventricular septal defects. We describe the case of a man with delayed presentation of a traumatic ventricular septal defect in whom colour Doppler flow mapping permitted conservative management after accurate noninvasive diagnosis.

Traumatic left ventricular aneurysm: report of a case with normal coronary arteries

A 26-year-old male had an anterior myocardial infarction following blunt chest trauma. He developed a left ventricular aneurysm despite coronary angiography being normal.

Traumatic laceration of a saphenous vein graft: successful surgical repair

Traumatic laceration of a saphenous vein grafted for coronary artery bypass is extremely rare. Successful surgical repair of a laceration was performed in a 64-year-old man who developed retrosternal hematoma from a saphenous vein graft after blunt injury to the chest.

Myocardial infarction caused by blunt chest injury: possible mechanisms involved--case reports

Two cases are reported in which blunt chest trauma caused myocardial infarction. Coronary angiography revealed apical aneurysms in both patients with normal coronary arteries in the first and total occlusion of left anterior descending artery in the other. The main possible mechanisms of myocardial infarction after blunt chest trauma are discussed.

Advanced techniques in thoracic trauma

Technologic aid is available for the three central problems of hemorrhage, lung damage, and cardiac damage. Autotransfusion, new modes of ventilator support, extracorporeal oxygenation, balloon pumping, and left ventricular assist are available for the trauma patient. The author explains these new devices and their role in thoracic trauma cases.

The injured heart

Penetrating and blunt injuries to the heart, ranging from cardiac concussion to rupture, are seen more and more frequently. Prompt diagnosis because of a high index of suspicion and timely, well-executed resuscitative efforts are rewarded by remarkable survival rates, even in the patients presenting in extremis, whereas hesitancy in diagnosis and therapeutic action militates against a successful result.

Injury biomechanics research: an essential element in the prevention of trauma

The central aspects of injury biomechanics research are defined and research approaches described. These aspects include the identification and definition of impact injury mechanisms, the quantification of biomechanical response to impact, the determination of impact tolerance levels, and the development and use of injury assessment devices and techniques for evaluating injury prevention systems. The current status of knowledge and technology is then reviewed for the head, cervical spine, thorax, abdomen, and lower extremity. Important gaps are identified, and research priorities emphasizing functional impairment are proposed.

Myocardial contusion in patients with blunt chest trauma as evaluated by thallium 201 myocardial scintigraphy

Fifty five patients suffering from blunt chest trauma were studied to assess the diagnosis of myocardial contusion using thallium 201 myocardial scintigraphy. Thirty-eight patients had consistent scintigraphic defects and were considered to have a myocardial contusion. All patients with scintigraphic defects had paroxysmal arrhythmias and/or ECG abnormalities. Of 38 patients, 32 had localized ST-T segment abnormalities; 29, ST-T segment abnormalities suggesting involvement of the same cardiac area as scintigraphic defects; 21, echocardiographic abnormalities. Sixteen patients had segmental hypokinesia involving the same cardiac area as the scintigraphic defects. Fifteen patients had clinical signs suggestive of myocardial contusion and scintigraphic defects. Almost 70 percent of patients with blunt chest trauma had scintigraphic defects related to areas of myocardial contusion. When thallium 201 myocardial scintigraphy directly showed myocardial lesion, two-dimensional echocardiography and standard ECG detected related functional consequences of cardiac trauma.

Frequency of cardiac contusion in nonpenetrating chest injury

Seventy-five patients with nonpenetrating chest injuries were evaluated with electrocardiography, cardiac enzyme determination, 2-dimensional echocardiography and radionuclide ventriculography to document the incidence of cardiac abnormalities. Although the electrocardiograms showed ST-T wave changes in 25 patients (33%), sensitivity (47%) and specificity (79%) for echocardiographic and radionuclide abnormalities were poor. Cardiac enzymes were abnormal in 10 patients (13%), sensitivity for echocardiographic or radionuclide abnormalities, or both, was 29% and specificity 90%. Wall motion abnormalities were detected in 11 patients (18%) by radionuclide studies and in 3 patients (6%) by echocardiography. A pericardial effusion was present in 5 patients (10%). Two patients (4%) died of noncardiac causes; neither had wall motion abnormalities. This study documents the favorable outcome of patients with blunt chest injuries and does not suggest that echocardiography or radionuclide studies should be performed routinely on such patients.

Fatal traumatic heart block as a result of apparently minor trauma

We report a case of sudden death in an 18-year-old man who collapsed after falling prone onto a football. Although no external evidence of injury or cardiac contusion was noted, a right atrial endocardial tear extending through the conduction system was found at autopsy. This was thought to be responsible for his death and to explain the transient appearance of third-degree heart block during resuscitation.

Doppler echocardiographic detection of traumatic ventricular septal defect--a case report

A case of traumatic ventricular septal defect diagnosed by Doppler echocardiography is described. The characteristic pulsed Doppler findings of a left-to-right shunt were recorded and the two-dimensional echocardiographic images of septal interruption were shown. Combined Doppler and two-dimensional echocardiography enhances the ability to detect the presence of a ventricular septal defect. Doppler echocardiography appears to be a useful noninvasive imaging modality in the evaluation of patients with cardiac trauma.

Traumatic tricuspid insufficiency. An underdiagnosed disease

Twelve cases of traumatic tricuspid insufficiency (only three of which already have been published), collected in the same city, are reported. This figure strongly contrasts with the limited number of cases published to date in the literature. Emphasis is placed on the difficulty of diagnosis, the utility of echocardiography and Doppler ultrasound and therapeutic problems of this lesion.

Chest trauma: evaluation by two-dimensional echocardiography

Patients with either blunt or penetrating chest injuries may develop a variety of cardiac complications. The studies of 76 patients with suspected cardiac injury obtained over a 30-month period were reviewed in order to determine how frequently and in what manner two-dimensional echocardiography (2DE) is of value in the assessment of such patients. Thirty-nine patients had blunt trauma (group I), and 37 had penetrating trauma (group II). The 2DE findings in group I were: no visible abnormality in 19, pericardial effusions in six, and wall motion abnormalities in two; the studies were technically inadequate in six. In group II patients, the 2DE findings were: no visible abnormality in 14, pericardial effusions in 12, wall motion abnormalities in three, and unusual abnormalities such as foreign body or intrathoracic air in three; the studies were technically inadequate in four. This study shows that satisfactory 2DE can be performed in up to 87% of unselected patients who sustain chest injuries and does provide clinically valuable information that cannot be easily obtained by other noninvasive tests. In this series, 2DE was of greatest value in the detection of pericardial effusions that were present in 27% and of unusual abnormalities including intrathoracic air and foreign bodies such as a bullet.

Triple diaphragmatic rupture with disruption of the pericardium: pericardial reconstruction by lyophilized dura allograft

A patient is described with the unusual findings of intrapericardial diaphragmatic rupture combined with total disruption of the pericardium and partial abruption of the diaphragm from its costal origin. Through a third traumatic diaphragmal leak, the small intestine had prolapsed intercostally without contact to the pleural space. Surgical repair was done by direct diaphragmatic suturing and lyophilized dura allograft reconstruction of the left pericardial circumference. Postoperatively, atrioventricular block secondary to myocardial contusion necessitated pacemaker implantation. The patient left the hospital five weeks after the injury.

Aneurysm of left ventricle and left coronary artery after non-penetrating chest trauma

A 17 year old boy who sustained blunt chest trauma to his chest developed a proximal left anterior descending coronary artery aneurysm and an aneurysm of the left ventricle. He underwent left ventricular aneurysmectomy and was discharged to outpatient follow up.

Echocardiographic detection of pneumomediastinum and pneumopericardium: the air gap sign

Six patients referred for echocardiographic evaluation in whom an unusual echocardiographic sign resulted from air within the mediastinum or pericardium are described. Three patients had a pneumomediastinum that occurred after chest trauma and three patients had a pneumopericardium induced during a therapeutic pericardiocentesis. Important features included a broad band of echoes (air) recorded during held respiration which obscured the normal cardiac structures and dropout (gap) of echoes posteriorly. Between the cyclic appearance of the "air gap" sign, intracardiac structures were normally visualized. Echocardiographic recording of the air gap sign was identical in the six cases; it disappeared after resolution of clinical signs and symptoms of the pneumopericardium or pneumomediastinum. The pattern most likely resulted from air within the anterior mediastinum or pericardium interfering with the echographic beam and resulted in a cyclic appearance from systole to early diastole as the air was displaced by the changing cardiac size. Recognition of the air gap sign can be helpful in evaluating patients for pneumomediastinum or pneumopericardium after thoracic trauma.

Two-dimensional echocardiographic findings in cardiac trauma

Cardiac contusion is a potentially fatal complication of blunt chest trauma. The diagnosis is obscured because cardiac contusion usually occurs in a setting of multisystem trauma. Furthermore, the electrocardiographic changes are nonspecific. Experience with 2-dimensional echocardiography in evaluating cardiac trauma has not previously been emphasized. This report examines the results of 2-dimensional echocardiographic examinations in 7 patients after significant blunt chest trauma. Generalized right ventricular dilatation was identified in 4 cases; superimposed segmental areas of right ventricular dilatation occurred in 3. Three patients had localized myocardial thinning, and segmental wall motion abnormalities occurred in 2. Additional abnormalities identified included ventricular thrombi (4 right and 1 left ventricular), fibrinous pericardial effusion (1), ruptured tricuspid chordae with flail leaflet (1), and a small aneurysm of the sinus of Valsalva (1). It is concluded that 2-dimensional echocardiography is useful for diagnosing cardiac contusion, for estimating the extent of myocardial damage, and for identifying accompanying cardiac lesions such as thrombi, pericardial effusion, and valvular disruption.

Traumatic sinus node dysfunction

A 50-year-old man exhibited sinus node dysfunction following non-penetrating chest trauma. Transiently elevated cardiac isoenzymes, together with normal past electrocardiograms, support the contention that the blunt chest trauma was responsible for the sinus node dysfunction. This case suggests that this condition may occur more frequently than expected and remain unrecognized. Temporary and subsequent permanent pacing may be necessary. Also emphasized is the potential for liability issues.