Eur J Cardiothorac Surg 2002;22:154-156
© 2002 Elsevier Science NL
Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma
Christof Stamma,
Lloyd R. Feitb,
Tal Gevac,
Pedro J. del Nidoa*
a Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
b Pediatric Cardiology, Hasbro Children's Hospital, Providence, RI, USA
c Department of Cardiology, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
Received 22 November 2001;
received in revised form 18 February 2002;
accepted 22 March 2002.
* Corresponding author. Tel.: +1-617-355-8290; fax: +1-617-232-2697
e-mail: pedro.delnido{at}tch.harvard.edu
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Abstract
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In children, even minor trauma to the chest can result in cardiac injury. We describe a case of a 13-year-old boy who received blunt chest trauma during a motorcycle accident. He was initially symptom-free but later complained of persistent chest pain and a murmur was noted. An anterior muscular ventricular septal defect was detected one day after the accident, and a left ventricular pseudo-aneurysm developed days later. Both were successfully repaired 3 weeks after the injury.
Key Words: Trauma • Heart • Aneurysm • Surgery • Ventricular septal defect
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1. Introduction
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Severe, non-penetrating chest trauma is frequently associated with cardiac injury [1]. Rapid deceleration forces the heart against the anterior chest wall and provokes excessive shear forces on cardiac structures. Compression of the chest can lead to excessive intraventricular pressure and result in acute rupture of the ventricular free wall or interventricular septum. Furthermore, coronary arteries, atrioventricular valves, and ventriculoarterial valves can be directly injured. In addition, blunt chest trauma can also result in primarily non-structural myocardial damage, i.e. myocardial contusion [2]. While direct rupture of cardiac structures typically leads to acute hemodynamic decompensation, myocardial contusion is often symptom-free and difficult to diagnose because it is not always associated with impaired cardiac function or release of cardiomyocyte-specific enzymes.
Here, we present a case of a blunt chest trauma that combines both direct myocardial injury in the form of a traumatic ventricular septal defect (VSD), with delayed development of a left ventricular (LV) pseudo-aneurysm following myocardial contusion.
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2. Case report
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In a motorcycle accident, a 13-year-old boy was hit in the chest by the handlebar. No injury was apparent initially, but he developed chest pain that night. He was taken to the emergency room where a computed tomography (CT) scan was performed, which showed no abnormalities. On the following day his mother noted unusual chest wall motion and an unusual sound not heard in his sister's chest prompting evaluation at their general practitioner's office, who referred the patient for echocardiographic evaluation in a week. One week after the initial trauma, echocardiography showed a restrictive antero-apical VSD without evidence of ventricular dysfunction. On physical examination, a long blowing holosystolic murmur graded 4/6 was heard throughout the precordium. The echocardiogram was repeated 7 days later and showed no change in the size of the VSD or LV wall abnormalities. The echocardiogram (EKG) at this time, however, showed ectopic ventricular beats and the patient was started on atenolol. Four days later another EKG was performed which demonstrated evidence of a LV free wall aneurysm in addition to the VSD. The patient was then referred to Children's Hospital Boston and a cardiac magnetic resonance imaging (MRI) was obtained, which demonstrated an anterior mid-muscular VSD measuring 15 mm in diameter, partly covered by right ventricular muscle bundles that restricted the flow across the defect (Fig. 1 ). The VSD was in continuity with an antero-apical pseudo-aneurysm of the LV free wall. The aneurysm measured 28x25 mm and extended from the anterolateral papillary muscle of the mitral valve to the anterolateral segment of the interventricular septum. Coronary angiography demonstrated that all the vessels were patent, but a large diagonal branch bulged paradoxically over the aneurysm and occluded during systole (Fig. 2
). The operative findings demonstrated a pseudo-aneurysm of the LV free wall measuring approximately 3.5 cm in diameter in the area directly under the first diagonal branch. On cardiopulmonary bypass, the aneurysm was incised during ventricular fibrillation and a well-circumscribed septal defect was visualized through the opened aneurysm at the anterior part of the septum. The VSD was closed with a patch of double velour Dacron sewn on the left septal surface with running sutures and reinforced with pledgeted sutures. The wall of the aneurysm consisted only of a thin layer of epicardium and a clear edge was identified circumferentially. Sutures were passed lateral to both the diagonal and the LAD, and a sandwich patch of autologous pericardium and Dacron was used to close the pseudo-aneurysm. The free edges of the aneurysm were then approximated over the Dacron patch. The patient was weaned from bypass without problems, and transesophageal echocardiography showed no residual septal defects and good ventricular function. There were no postoperative complications except a brief episode of ventricular tachycardia early after surgery that was controlled with Lidocaine. The patient was discharged on postoperative day 4 on atenolol and aspirin. Eight months after the operation he has no cardiac symptoms and there is no evidence of residual or recurrent VSD or LV aneurysm by echocardiography. Follow-up Holter showed no ectopy and a Bruce protocol treadmill stress test showed no inducible ectopy or ST segment abnormalities. He has fully resumed his normal activities.
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Fig. 1. Fast spin echo with double inversion recovery magnetic resonance images in short axis (A) and long axis (B) demonstrating the large muscular VSD (solid arrow) partially covered by right ventricular muscle bundles, and the left ventricular false aneurysm (open arrow).
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Fig. 2. Coronary angiography demonstrating the first diagonal branch passing over the LV aneurysm and occluded during systole (arrow).
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3. Discussion
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We present this case of myocardial injury following blunt chest trauma because it combines features of both a traumatic VSD with limited shunt volume due to right ventricular muscle bundles, and a LV pseudo-aneurysm secondary to myocardial contusion and/or incomplete rupture of the LV free wall. Rupture of the ventricular septum is believed to occur due to compression of the chest while the ventricles are filled and the atrioventricular valves closed, resulting in excessive intraventricular pressure. When a large unrestrictive intraventricular communication results, hemodynamic decompensation develops rapidly. In our case, the VSD was large but partially covered by right ventricular muscle bundles, rendering it restrictive, thus limiting the left to right shunt. This probably explains the fact that no signs of hemodynamic decompensation were present. The development of the LV pseudo-aneurysm in our case is most likely related to the myocardial contusion and rupture of the inner layers of the LV free wall that occurred when the anterior surface of the heart was violently forced against the anterior chest wall. Disruption of coronary blood flow or intramural hematoma have also been described as causes of LV aneursym, but no evidence for either mechanism was found in angiography, MRI or echocardiography studies [3,4]. To the best of our knowledge, only five cases of successful repair of combined VSD and LV aneurysm following blunt chest trauma have been described in the literature. Green et al. [5] reported the first case of a 10-year-old boy in 1965. Reginato et al. [6] described a case of early VSD closure and mitral valve replacement followed by closure of a residual VSD and resection of a LV aneursym 11 months after the injury. Ollivier et al. [7] repaired a VSD and LV aneurysm 9 months after a blunt thoracic trauma, Grieco et al. [8] presented a case of delayed VSD closure and aneurysm repair in a patient with traumatic occlusion of the LAD, and Tiao et al. [9] described a 3-year-old boy with early surgery for VSD closure and LV aneurysm who subsequently required resection of a recurrent aneurysm.
It is well established that myocardial contusion is frequent in patients with severe non-penetrating chest trauma. Especially in children and adolescents with a flexible chest wall, the heart can be traumatized without obvious external injuries. Once cardiac injury is suspected structural damage must be excluded using echocardiography, which should be repeated after several days due to the possibility of delayed rupture. Whenever the echocardiography evaluation leaves doubts, cardiac MRI can help to delineate structural damage of ventricular free wall and septal structures. Even extensive injury to cardiac structures can then be repaired with good results.
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Acknowledgments
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We are indebted to Dr Ingeborg Friehs for her invaluable help in preparing the manuscript.
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References
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- Pretre R., Chilcott M. Blunt trauma to the heart and the great vessels. N Engl J Med 1997;336:626-632.[Free Full Text]
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- Green L., Oakley C.M., Davies D.M., Cleland W.P. Sucessful repair of left ventricular aneurysm and ventricular septal defect after indirect injury. Lancet 1965;2(7420):984-986.[Medline]
- Reginato E., Speroni F., Ricardi M., Verunelli F., Eufrate S. Post-traumatic mitral regurgitation and ventricular septal defect in absence of left pericardium. Thorac Cardiovasc Surg 1980;28:213-217.[Medline]
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Abstract
1. Introduction
