Incomplete ventricular septal tear after blunt chest trauma: medical management with serial echocardiographic follow-up

Interventricular Septal Pseudoaneurysm After Blunt Chest Trauma in a 6 Year Old: An Illustrative Case and Review

Motor vehicle accident is the most common cause of blunt cardiac injury (BCI) in children (85.3%) due to the height of the child in relation to proper restraints and the compliant pediatric rib cage (J Trauma. 1996;40:200-202). Trauma to the chest wall may lead to injury of the myocardium, resulting in myocardial contusion, ventricular septal defect (VSD), ventricular free wall rupture, or valve compromise (J Trauma. 1996;40; 200-202; Heart Lung. 2012;41:200-202; J Inj Violence Res. 2012;4:98-100). There are several proposed mechanisms for the formation of VSD after blunt chest trauma including rupture of ischemic myocardium related to the initial trauma and reopening of a spontaneously closed congenital VSD. Also, chest trauma during isovolumetric contraction of the ventricles may generate enough intraventricular force to cause myocardial rupture (J Trauma. 1996;40:200-202; J Inj Violence Res. 2012;4:98-100; Korean J Pediatr. 2011;54:86-89; Ann Thorac Surg. 2012;94:1714-1716; J Emerg Trauma Shock. 2012;5:184-187). Previous case reports highlight the formation of a true VSD after BCI and the requirement of emergent repair (J Emerg Trauma Shock. 2012;5:184-187; Am Heart J. 1996;131:1039-1041; Korean Circ J. 2011;41:625-628; Ann Thorac Surg 2013;96:297-298; Kardiol Pol. 2013;71:992; Chin Med J. 2013;126:1592-1593). Reported is a case of a 6-year-old girl who developed an interventricular septal pseudoaneurysm after a motor vehicle accident of pedestrian versus car. On the day of presentation, she developed bradycardia after emergent surgical repair for abdominal trauma that required cardiopulmonary resuscitation including 5 minutes of chest compressions. At the time of resuscitation, an emergent transthoracic echocardiogram noted an interventricular pseudoaneurysm. She has been followed with serial transthoracic echocardiograms and has not required surgical intervention. We discuss the risk factors, prevalence, and diagnostic studies and recommended treatment options for structural heart disease after BCI.

Incomplete Ventricular Septal Rupture Following Blunt Chest Trauma

This report describes a case of traumatic incomplete rupture of the ventricular septum, a rare complication caused by blunt chest trauma. Although a serial ECG progressed its course similar to acute anteroseptal myocardial infarction in this case, there was little clinical clue of septal tear. The diagnosis was established by transthoracic echocardiography. The authors chose a conservative line of management rather than surgical repair for incomplete septal rupture because of the patent’s stable clinical course and hemodynamic status. A sequence of echocardiography during a 32-day stay in the hospital showed no change in the extent of incomplete septal rupture, septal structure, systolic function, and shape of left ventricle and also obtained no evidence of shunting through the rupture. In conclusion, echocardiography is a useful investigation to make a diagnosis as well as for follow-up in case of incomplete ventricular septal rupture. A close follow-up of incomplete septal rupture with serial echocardiography should be performed, because several cases of delayed ventricular septal rupture following blunt chest trauma have been reported.

Partial tearing of the interventricular septum after blunt chest trauma

Cardiac trauma after blunt chest trauma is a rare complication of patients arriving alive to an emergency department. We here present the case of patient who had a partial rupture of the interventricular septum after having had a blunt chest trauma in a traffic accident. As there was no ventricular septal defect, conservative management was deemed appropriate. At 3-year follow-up, the patient was free of right heart failure symptoms suggestive of the septal defect progression.

Spontaneous healing of saccular type aneurysm with ventricular septal lacerations after blunt chest trauma

We present a case of spontaneous healing of saccular type aneurysm with ventricular septal lacerations after blunt chest trauma. A 50-year-old Japanese man was transferred to our hospital diagnosed with ventricular septal lacerations after blunt chest trauma. Electrocardiogram (ECG) at admission showed ST elevations in I, II, III, aVL, aVF, V2-through to V6 were observed. Laboratory data showed elevated creatine kinase. Echocardiogram revealed normal ventricular contraction and a saccular type ventricular septal laceration with an influx blood flow without septal shunt flow. After admission, serial echocardiogram and cardiac computed enhancement tomography showed disappearance of a saccular type ventricular septal laceration. Gadolinium-enhanced magnetic resonance imaging (MRI) was performed at day 30. MRI showed an enhanced scar of saccular type aneurysm with ventricular septal laceration; this image suggested some residual damage of ventricular septal laceration. At discharge, ECG was resolved with normal ST-T level and no Q wave, but persistent complete right bundle branch block and left axis deviation. After one year, repeat MRI showed a scar of saccular type aneurysm with ventricular septal laceration. <Learning objective: To recognize spontaneous healing of saccular type aneurysm with ventricular septal lacerations after blunt chest trauma. This is a case of saccular type aneurysm with ventricular septal laceration after non-penetrating blunt chest trauma successfully healed with conservative therapy. There are many case reports of blunt chest trauma, however, there are few reports of treatment with conservative therapy.>.

Chest trauma: the role of transesophageal echocardiography

Aortic and cardiac injury is commonly seen with severe chest trauma and contributes to the morbidity and mortality of automobile accidents. Transesophageal echocardiography is emerging as an important diagnostic tool for the evaluation of cardiovascular injury in the setting of acute chest trauma, and anesthesiologists should be familiar with the echocardiographic features of these traumatic lesions.

Transesophageal echocardiography in the evaluation of cardiothoracic trauma

TEE has been used in the past 13 years to examine the heart and thoracic aorta, and recently the clinical utility of TEE has greatly expanded to include its use in a variety of thoracic trauma injuries. We retrospectively reviewed the use of TEE in our institution from June 1994 to June 1995. Sixteen patients underwent TEE for a variety of indications, including traumatic aortic dissection, penetrating wounds to the precordium, retrieval of a foreign body, valvular trauma, and postoperative evaluation of cardiac repair. TEE affected patient treatment decisions in all of these cases. As a diagnostic modality and as a guide to specific therapy, TEE was safe, expedient, accurate, and highly valuable in the evaluation of patients with trauma to the heart or great vessels.

Intracardiac shunts

Unsuspected intracardiac shunts can be a cause of acute deterioration in critically ill patients. Shunts can be acquired or congenital conditions that become symptomatic only with changed physiologic conditions. Transesophageal echocardiography is an excellent tool for the diagnosis of intracardiac shunts.