Post-traumatic intracardiac shunts

Trauma Associated with Cardiac Conduction Abnormalities: Population-Based Perspective, Mechanism and Review of Literature

OBJECTIVES

Various cardiac conduction abnormalities have been described as being a result of trauma in many case reports. The aim of this research was to look at the association between trauma (thoracic and cardiac) and conduction abnormalities in a large hospitalized population.

METHODS

Cases diagnosed with trauma and various cardiac conduction disorders were identified based on ICD-9-CM discharge diagnoses from 986 acute general hospitals across 33 states in 2001.

RESULTS

Independent of potential confounding factors, discharge for blunt cardiac injury (BCI) was associated with a threefold increased risk for cardiac conduction abnormalities (95% confidence interval 2.45-4.51) during hospitalization in 2001. Both BCI and thoracic trauma had a significant association with right bundle branch block (RBBB) in this study (OR 6.04; 95% confidence interval (CI) 3.77-9.67 and OR 1.75; 95% CI 1.38-2.23 respectively).

CONCLUSIONS

The results of this study demonstrate the impact of trauma on cardiac conduction abnormalities. This study represents an attempt to consider a mechanism of a complex traumatic cardiac event from a population-based perspective, and may improve the prognosis for patients diagnosed with cardiac or thoracic injuries.

Diagnosis and management of traumatic aorto-right ventricular fistulas

BACKGROUND

Traumatic aorto-right ventricular (Ao-RV) fistulas are rare lesions that result in congestive heart failure if left untreated. Early diagnosis and prompt surgical intervention are required to avoid the natural outcome of cardiac decompensation.

METHODS

All cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed. The clinical presentation, methods of diagnosis, and treatment strategies were assessed to determine the pathophysiology, natural history, and outcome of surgical intervention.

RESULTS

Forty cases of traumatic Ao-RV fistulas were described in the English literature. There were 39 men and 1 woman, with a mean age of 28.3 years (range, 15 to 50 years). Twenty-two (55%) patients had isolated Ao-RV fistulas. Fourteen (35%) had Ao-RV fistulas with aortic insufficiency. Definitive surgical repair was performed in 38 patients. The associated aortic valve injuries were managed with repair techniques or replacement with prosthetic devices. The surgical outcomes in all patients were satisfactory.

CONCLUSIONS

The pathophysiology and natural history of Ao-RV fistulas involves the development of congestive heart failure. Traumatic aortic insufficiency frequently is associated with this disorder. Early diagnosis and prompt treatment are necessary to avoid the natural outcome of cardiac decompensation. Definitive repair should be performed with the aid of cardiopulmonary bypass during the same hospitalization.

Sequelae of injury to the heart caused by multiple needles

A case is reported in which multiple needles were inserted into the heart by a patient, resulting in the unusual combination of a coronary artery-cameral fistula to the left ventricle, an intramural defect of the left ventricular free wall and a ventricular septal defect. This unique lesion was suspected on the basis of two-dimensional and Doppler echocardiography and contrast computed tomographic imaging. Its presence was confirmed during cardiac catheterization and cineangiography.

Penetrating and perforating thoracic injuries

Five hundred and eleven patients with penetrating or perforating chest injuries were admitted to the Department of Thoracic and Cardiovascular Surgery, University Central Hospital, Helsinki, during the 25-year-period 1952-77. There were 433 stab wounds, 59 gunshot wounds and 19 other penetrating injuries. The organs most often involved were lungs (major haemo- or pneumothorax in 385 patients), heart (63 patients) and liver (61 patients). About one third of the patients were in profound shock on admission. The treatment was immediate thoracotomy in 176 (35%) and laparotomy in 123 cases (24%). Tube thoracostomy was applied in 117 patients and needle aspiration performed in 88 patients. Nine patients died (mortality of 1.8%). Two patients required later open-heart procedure. One of them had an aortopulmonary fistula and the other a traumatic VSD combined with aortic valve lesion. One of the traumatic VSDs closed spontaneously during the follow-up time. An active operative approach in the early phase seems to guarantee the best final results, especially in the most critically ill patients.

Elective correction of intracardiac lesions resulting from penetrating wounds of the heart

Controversy exists regarding the timing and technique of total correction of traumatic intracardiac lesions. Five patients with penetrating wounds of the heart received emergency treatment aimed at securing normal haemodynamics. No attempt was made to identify intracardiac lesions at this stage. Cineangiography two months to seven years later showed aorto-right ventricular fistulae in all patients, associated in two with aortic cusp laceration and in one with an aorto-left atrial fistula. The surgical approach for aorto-right ventricular fistula was through the right ventricle or aorta. Valvar injuries were treated by plastic reconstruction. All patients showed good clinical results when seen four to 11 years later. Traumatic intracardiac lesions in patients with stable haemodynamics after initial treatment should be operated on electively. The aortic approach is preferable for aorto-right ventricular fistulae. Conservative plastic repair of valvar injuries achieves long-term competence thus avoiding prosthetic replacement.