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Ann Thorac Surg 1996;61:710-711
© 1996 The Society of Thoracic Surgeons

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Case Report

Surviving Resuscitation: Successful Repair of Cardiac Rupture

Departments of Cardiothoracic Surgery, Cardiology, and Thoracic Physiology, Karolinska Hospital, Stockholm, Sweden

Accepted for publication August 2, 1995.

	Abstract

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An 83-year-old man was found unconscious and was successfully resuscitated. Progressive cardiac failure developed. After 42 hours of observation echocardiography revealed cardiac tamponade and a discontinuity in the left atrial wall. Exploration showed a laceration of the left atrium at the junction of the left pulmonary veins, which was closed with a direct suture on cardiopulmonary bypass. The postoperative course was uneventful.

	Introduction

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An 83-year-old man with inactive rheumatoid arthritis and a history of direct-current cardioverted atrial fibrillation in the 1970s lost conciousness in his home. A neighbor initiated external heart massage, which was continued by the ambulance staff on the way to the hospital. On arrival at the hospital the patient was semiconscious and complaining of a headache. The physical examination revealed a systolic blood pressure of 80 to 90 mm Hg and a pulse rate of approximately 90 beats/min. An electrocardiogram was nonconclusive. The neurologic examination showed exaggerated tendon reflexes on the left side, and an emergency computed tomographic scan showed suspicion of a thrombus of the medial cerebral artery.

The patient was admitted to a neurology ward for observation. During the time of observation the blood pressure dropped twice to an unmeasurable level while the patient was straining, but was otherwise approximately 100 mm Hg systolic. The heart rate increased to 120 beats/min. Physical examination revealed rhales of the lungs and edema of the legs. The blood tests showed elevated liver enzyme levels. Ultrasonography of the liver and pancreas was performed and found to be normal. The patient was treated with fluids and intravenous diuretics. A roentgenogram of the chest 36 hours after admission showed signs of congestion and an enlarged heart. After 42 hours of observation the patient exhibited no focal neurologic signs but manifestations of cardiac failure despite aggressive treatment.

On arrival in the cardiac intensive care the patient had a systolic blood pressure of 110 mm Hg, sinus rhythm of 100 beats/min, and rhales of the lungs. To investigate the cause of biventricular failure in a patient without a history of cardiac failure we immediately performed transthoracic echocardiography, which revealed cardiac tamponade with the echogenic character of liquid and coagulated blood. An attempt to aspirate from the pericardium was unsuccessful. The aortography was normal. Out of fear of further compromising the patient's already precarious situation, we then took the patient to the operating room, where he was dressed and anesthetized before transesophageal echocardiography was performed. The systolic blood pressure was 125 mm Hg and the heart rate was 110 beats/min. The examination revealed a discontinuity of the left atrial wall (Fig 1).

View larger version (103K): [in this window] [in a new window]   Fig 1. . Transesophageal echocardiogram, modified four-chamber view showing ruptured left atrial (LA) wall. There is also a compression of the LA caused by clotted blood in the pericardium. (LV = left ventricle; RV = right ventricle.)

View larger version (17K): [in this window] [in a new window]   Fig 2. . Site of laceration (lateral view of the heart). Arrow indicates site of laceration. (AO = aorta; PA = pulmonary artery.)

	Comment

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This case is rare in two regards, cause and the patient's survival despite delayed diagnosis and treatment. Rupture of almost all structures in the thoracic cavity has been described [1]. The mechanism could be acceleration/deceleration, crush injury, or penetrating injury [2, 3]. The most common cause of blunt trauma is motor vehicle accidents [3]. A few cases of rupture of the heart after external heart massage can be found in the autopsy material presented by Bodily and Fischer [4]. Sethi and associates [5] presented a case report of a man who had undergone a coronary bypass operation with fracture of the sternum where external massage caused laceration of the outflow tract of the right chamber. As far as we know only 1 patient has survived this complication, the 4-year-old boy described by Reardon and colleagues [6] who survived a 3-day delay of diagnosis after sustaining a laceration of the right atrium.

Our case illustrates that tamponade of the heart is not immediately fatal in all cases. However, the importance of rapid diagnosis and treatment is stressed in all publications. With the aid of echocardiography the cardiac tamponade could have been discovered in the emergency room. The diagnosis of cardiac failure was based on signs of congestion on the chest film compunded with rhales and edema of the legs. Congestion of the systemic circulation was caused by the cardiac tamponade and reduced return of blood to the heart. Congestion of the pulmonary circulation could be a result of the tamponade of the left atrium created by a clot at the rupture site, which impeded the return of blood from the lungs.

Although uncommon, the material discussed demonstrates the possibility of cardiac rupture as a complication of external cardiac massage. More extensive use of echocardiography in the evaluation of sudden onset of heart failure or of the resuscitated patient by experienced physicians could be of great value.

	Footnotes

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Address reprint requests to Dr Bitkover, Department of Cardiothoracic Surgery, Karolinska Hospital, S- 171 76 Stockholm, Sweden.

	References

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1. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma. Ann Surg 1987;206:200–5.[Medline]
2. Pevec WC, Udekwu AO, Peitzman AB. Blunt rupture of the myocardium. Ann Thorac Surg 1989;48:139–42.[Abstract/Free Full Text]
3. LoCicero J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69:15–9.[Medline]
4. Bodily K, Fischer RP. Aortic rupture and right ventricular rupture induced by closed chest cardiac massage. Minn Med 1979;62:225–7.[Medline]
5. Sethi GK, Scott SM, Takaro T. Complications of external cardiac massage: report of a case of laceration of the right ventricular outflow tract. J Cardiovas Surg 1977;18:187–90.[Medline]
6. Reardon MJ, Gross DM, Vallone AM, Weiland AP, Walker WE. Atrial rupture in a child from cardiac massage by his parent. Ann Thorac Surg 1987;43:557–8.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Catarina Y. Bitkover Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bitkover, C. Y. Articles by Liska, J. Search for Related Content PubMed PubMed Citation Articles by Bitkover, C. Y. Articles by Liska, J.