Delayed diagnosis of traumatic ventricular septal defect in penetrating chest injury: small evidence on echocardiography makes big difference

Ventricular Septal Defect and Mitral Regurgitation Due to Penetrating Cardiac Trauma; a Case Report and Review of Literature

Penetrating cardiac trauma is a fatal condition and can result in the injury of various parts of the heart. Ventricular Septal Defect (VSD) following these traumas occurs only in 1-5% of cases. The patients' conditions depend on location, size, and concomitant injuries. One of the uncommon coincidences with the VSD is Mitral Regurgitation (MR) due to injury to sub-valvular structures. In this study, we report a case of concomitant traumatic-induced VSD and MR in a 14-year-old boy following a stab wound to his chest. The patient was a teenage boy coming to the Rajaei Cardiology Hospital emergency room following a stab wound to the anterior and left part of his chest. Despite primary urgent surgery, his breathlessness had continued for three more months. Evaluations with Transthoracic Echocardiography (TTE) revealed VSD with concomitant MR, but there was no papillary muscle rupture. Cardiac Magnetic Resonance Imaging (MRI) and angiographic evaluation confirmed the provisional diagnosis. The Amplatzer VSD occluder repaired the VSD, and the patient was discharged following the resolution of his symptoms. Although the MR has been present in the follow-up echocardiography, the patient has been asymptomatic. Since the initial presenting symptoms and signs of VSD and MR might be subtle or delayed, imaging modalities such as TTE and Transesophageal Echocardiogram (TEE) are beneficial in determining the diagnosis and the optimal treatment.

A meta-analysis of the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma

BACKGROUND

We performed a systematic review (SR) and meta-analysis (MA) to determine the diagnostic accuracy of chest ultrasound (US) compared with a pericardial window (PW) for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma.

METHODS

A literature search in five databases identified relevant articles for inclusion in this SR and MA. Studies were eligible if they evaluated the diagnostic accuracy of chest US, compared with a PW, for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients presenting with penetrating thoracic trauma. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. Methodological quality was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2. We performed a MA of binary diagnostic test accuracy within the bivariate mixed-effects logistic regression modeling framework.

RESULTS

We included five studies in our SR and MA. These studies included a total of 556 trauma patients. The MA found that, compared with PW, the US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients. The presence of a concomitant left hemothorax was frequent in patients with false-negative results.

CONCLUSION

This SR and MA found that, compared with PW, US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. Caution interpretation of pericardial US results is suggested in the presence of left hemothorax. In these cases, a second diagnostic test should be performed.

LEVEL OF EVIDENCE

Systematic Review and Meta-analysis, level II.

The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients

BACKGROUND

There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country.

METHODS

Data were collected prospectively. We included all consecutive patients 14 years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90 mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test.

RESULTS

A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions.

CONCLUSION

We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

Ventricular Septal Rupture After Blunt Chest Trauma in an Infant: A Case Report and Mini-Review

Ventricular septal rupture (VSR) due to blunt chest trauma (BCT) is rare in infants. Traumatic VSR should be considered in infants with acute congestive cardiac failure following blunt trauma to the chest. Echocardiography is the method of choice for diagnosis and guiding the management of VSR. In this case report, we present a case of VSR caused by BCT in a 1-year and 9-month-old infant, who was diagnosed by emergency bedside echocardiography. We also provide a mini-review of literatures on BCT-induced VSR in children.

Delayed diagnosis of traumatic ventricular septal perforation in penetrating chest injury: hematoma formation in the ventricular septum in CT suggests perforation

Background

Ventricular septal perforation (VSP) can be caused by a penetrating cardiac injury. Diagnosis of VSP tends to be delayed because a shunt might not be detected by color flow Doppler at an early stage following injury.

Case presentation

A 60‐year‐old man with depression was admitted to the emergency center after a knife injury in the chest. A focused assessment with sonography for trauma revealed cardiac tamponade. Shortly after an open cardiac massage and a pericardiotomy, his spontaneous circulation returned. At a later stage, follow‐up computed tomography, echocardiography, and left ventriculography showed traumatic ventricular septal perforation. Conservative therapy was chosen because the pulmonary blood flow/systemic blood flow ratio was 1.42.

Conclusion

The initial contrast computed tomography shows a septal hematoma. Its presence could be perceived as a perforation site in the interventricular septum.

Screening for occult penetrating cardiac injuries

OBJECTIVE

To determine the sensitivity of emergency department ultrasonography (US) in the diagnosis of occult cardiac injuries.

BACKGROUND

Internationally, US has become the investigation of choice in screening patients for a possible cardiac injury after penetrating chest trauma by detecting blood in the pericardial sac.

METHODS

Patients presenting with a penetrating chest wound and a possible cardiac injury to the Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 were prospectively evaluated. All patients were hemodynamically stable, had no indication for emergency surgery, and had an US scan followed by subxiphoid pericardial window exploration.

RESULTS

There were a total of 172 patients (median age = 26 years; range, 11-65 years). The mechanism of injury was stab wounds in 166 (96%) and gunshot wounds in 6. The sensitivity of US in detecting hemopericardium was 86.7%, with a positive predictive value of 77%. There were 18 false-negatives. Eleven of these false-negatives had an associated hemothorax and 6 had pneumopericardium. A single patient had 2 negative US examinations and returned with delayed cardiac tamponade.

CONCLUSIONS

The sensitivity of US to detect hemopericardium in stable patients was only 86.7%. The 2 main factors that limit the screening are the presence of a hemothorax and air in the pericardial sac. A new regimen for screening of occult injuries to make allowance for this is proposed.

Imaging assessment of gunshot wounds

Gunshot injuries occur when someone is shot by a bullet or other sort of projectile from a firearm. Wounds are generally classified as low velocity (less than 609.6m/s) or high velocity (more than 609.6m/s). Those with higher velocity may be expected, on this basis, to dissipate more energy into surrounding tissue as they are slow and cause more tissue damage, but this is only a very approximate guide. However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as the kinetic energy, stability, entrance profile and path traveled through the body, and the biological characteristics of the tissues injured. Hemodynamically stable patients and patients who stabilized after simple immediate resuscitation were evaluated with a careful history and physical examination. A routine x-ray is performed in patients with gunshot wounds. Indication for total body computed tomography (CT) is based on the presence of signs and symptoms of vascular damage at clinical examination. Patients are immediately transferred in the operating room for surgery if more serious injuries that require immediate surgical care are not diagnosed, or hemostasis may be preliminary reached in the emergency room. Hemodynamically stable patients with no history and clinical examination showing suspected vascular damage are allowed in the radiology department for obtaining a total body CT scan with intravenous contrast medium and then transferred to the surgical ward trauma for observation. After 24 hours without the complications, patient can be discharged. CT is the procedure of choice to identify hemorrhage, air, bullet, bone fragments, hemothorax, nerve lesion, musculoskeletal lesions, and vessels injuries and is useful for assessing medicolegal aspects as trajectory and the anatomical structures at risk.

Transcatheter device closure of a traumatic ventricular septal defect

A traumatic ventricular septal defect (VSD) resulting from blunt chest injury is a very rare event in children. The clinical symptoms and timing of presentation are variable, so diagnosis and management of traumatic VSD may be challenging. Decision to close the traumatic VSD is usually based on a combination of severity of heart failure symptoms, hemodynamics, and defect size. We present a case of a 7-year-old boy who was run over by a truck and presented with head and liver injury initially. He was subsequently found to have a traumatic VSD. The VSD was closed percutaneously.

Undetected Aorto-RV Fistula With Aortic Valve Injury and Delayed Cardiac Tamponade following a Chest Stab Wound: A Case Report

Introduction

Although a few patients will survive after penetrating cardiac injuries, some of them may have unnoticeable intracardiac injuries. The combination of aorto-right ventricular fistula with aortic valve injury is rare.

Case Presentation

A 19 year-old man referred with an aorto-right ventricular fistula accompanied with aortic regurgitation and delayed tamponade following a stab in the chest. The patient was scheduled for fistula repair, aortic valve replacement and pericardectomy two months after trauma.

Conclusions

To prevent missing intracardiac injury and also late cardiac injury complications, in all pericordial stab wounds, serial clinical examinations and serial echocardiography should be performed. In addition, cardiac injuries should be repaired during the same hospital stay.

Managing a traumatic ventricular septal defect with atrial septal defect occluder device

Traumatic ventricular septal defects are rare complications of blunt and penetrating chest trauma. Patients are usually referred because of shock or cardiac tamponade. Focusing on the critical condition of the patient leads to missing the presence of traumatic ventricular septal defects. In this case report, we introduce a patient with a large traumatic ventricular septal defect, which was diagnosed 40 days after a penetrating cardiac trauma and was finally treated with transcatheter closure.

Ventricular septal necrosis after blunt chest trauma

Ventricular Septal Defect (VSD) after blunt chest trauma is a very rare traumatic affection. We report here a case of blunt chest injury-related VSD and pseudoaneurysm. A 30-year old male truck driver was referred from a trauma center to our hospital seven days after a blunt chest trauma and rib fracture. The patient had severe pulmonary edema and echocardiography showed large VSD. Several mechanisms are involved in the pathogenesis of this affection including an acute compression of the heart muscle between the sternum and the spine, leading to excessive changes in the intrathoracic and most likely the intracardiac pressure after blunt chest injury. Traumatical patients with the same symptoms may be at risk of sudden death. Therefore, a high grade of suspicion is mandatory even without solid evidence of myocardial damage on the initial evaluation. In continue some hidden angles of this case was discussed. Given the prognostic implications of traumatic VSD with associated pseudoaneurysm, its detection has critical value for preventing its clinical sequelae.

Traumatic ventricular septal defect in a 4-year-old boy after blunt chest injury

Traumatic ventricular septal defect (VSD) resulting from blunt chest injury is a very rare event. The mechanisms of traumatic VSD have been of little concern to dateuntil now, but two dominant theories have been described. In one, the rupture occurs due to acute compression of the heart; in the other, it is due to myocardial infarction of the septum. The clinical symptoms and timing of presentation are variable, so appropriate diagnosis can be difficult or delayed. Closure of traumatic VSD has been based on a combination of heart failure symptoms, hemodynamics, and defect size. Here, we present a case of a 4-year-old boy who presented with a traumatic VSD following a car accident. He showed normal cardiac structure at the time of injury, but after 8 days, his repeated echocardiography revealed a VSD. He was successfully treated by surgical closure of the VSD, and has been doing well up to the present. This report suggests that the clinician should pay great close attention to the patients injured by blunt chest trauma, keeping in mind the possibility of cardiac injury.