Ann Thorac Surg 1998;65:1137-1138
© 1998 The Society of Thoracic Surgeons
Case Reports
Natural History of a Ventriculoatrial Fistula After a Gunshot Injury in 1945
Laszlo Selinger, MDa,
Klaus Werner, MDa,
Rolf Silber, MDb,
Ullrich Nellessen, MDa,
Gerhard Inselmann, MDa
a Medizinische Poliklinik, University of Würzburg, Würzburg, Germany
b Klinik für Herz- und Thoraxchirurgie, University of Würzburg, Würzburg, Germany
Accepted for publication October 28, 1997.
Address reprint requests to Dr Inselmann, Medizinische Poliklinik, Klinikstrasse 6-8, 97070 Würzburg, Germany
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Abstract
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We describe an exceptional case of a patient who suffered a penetrating heart injury from a gunshot wound in 1945 leading to a left ventricular–right atrial fistula. Despite the resulting left-to-right shunt the patient remained relatively asymptomatic for 50 years before the onset of congestive heart failure necessitated an operation.
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Introduction
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A 70-year-old man had been complaining of palpitations and atypical angina pectoris since his right thoracic gunshot injury in 1945 but had a quite normal exercise tolerance. As grade 2 to 3 effort dyspnea had developed in 1979, cardiac catheterization was performed. Although a diagnosis of a left-to-right shunt of 50% was made, he was treated conservatively. He was referred 15 years later with further deterioration of grade 3 exertional dyspnea. There was a history of high blood pressure; however, peripheral edema and cardiac events were absent.
On examination the patient looked unwell. He revealed a broadened apical impulse, epigastric pulsations, and a loud systolic murmur over the precordium, which in phonocardiography extended to the early diastole. On auscultation of the lungs there were moderate bibasilar rales. The liver was slightly enlarged. The electrocardiogram showed atrial fibrillation with a rate of 100 beats/min, a right QRS axis with incomplete right bundle-branch block, and ST depression in leads V3 to V6. Blood pressure was initially 180/90 mm Hg; later it was 110/60 mm Hg. The rest of the examination was unremarkable. Chest radiography displayed progressive cardiomegaly to both sides over the last 18 months with indication of pulmonary plethora.
Two-dimensional transthoracic echocardiography showed an enlargement of the right heart cavities, including the main pulmonary artery. An additional echo-free space marked a saccular aneurysm of the interatrial septum, filling and bulging in systole, thus demonstrating a continuity with a high-pressure chamber. In transesophageal echocardiography a thickened and calcified mass was seen in the region of the noncoronary cusp of the aortic valve. In color flow mapping there were strong turbulences in the right atrium between the aortic root and the insufficient tricuspid valve; only a small diastolic jet from the region of the aortic annulus could be visualized distinctly. Accordingly, the contrast study failed to demonstrate a washout phenomenon.
At cardiac catheterization, hemodynamic data showed a raised right atrial pressure (mean pressure, 22 mm Hg) and pulmonary pressure (60/22/35 mm Hg mean) with step-up in the oxygen saturation in the right heart cavities, indicating a pulmonic–aortic flow ratio of 2:1. Also the end-diastolic left ventricular pressure was elevated (23 mm Hg). Retrograde aortography showed a moderate aortic regurgitation and confirmed also a flow from the left ventricular outflow tract to the right atrium. Contrast medium persisted longer in the interatrial septum, marking a pseudoaneurysm. The function of the left ventricle was normal. Coronary angiography showed one-vessel disease of the circumflex artery. The bullet itself resided in the ventral mediastinum.
The patient underwent an operation, in which a fistula in calcified tissue between the left ventricle just beneath the annulus of the noncoronary aortic valve and the right atrium was found (Fig 1). A direct suture (with a plastic patch) of the aortic root was made along with a single coronary bypass graft. Postoperatively a pacemaker had to be implanted, and the patient recovered well.
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Fig 1. Overholt (arrow) in the original pathway of the bullet. (Ao = aorta; RA = opened right atrium.)
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Comment
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Penetrating cardiac wounds caused by gunshot injury have a prehospital mortality rate of up to 81% [1–4]; stab wounds have a lower mortality rate. There have been major changes in the handling of these injuries since the 1960s [5, 6]. Rapid transport systems and an aggressive surgical approach, even emergency room thoracotomy with cardiorrhaphy for patients who fail to respond to initial volume therapy, has brought a considerable improvement in outcome, even for patients "in extremis" or under cardiopulmonary resuscitation [6]. Secondary lesions are frequent and should be looked for very carefully in the postoperative period with echocardiography and cardiac catheterization. Repair should be carried out electively on symptomatic patients.
Despite a close work-up there are symptomless patients with severe injuries in whom late sequelae develop after many years. Less is known about the natural history of these [7]. Our case delivers an example of the natural history of a combined lesion with traumatic ventriculoatrial defect with associated aortic regurgitation and atrial pseudoaneurysm [3] that developed symptoms after a long period of time. There are only a small number of cases of traumatic ventriculoatrial shunts reported [2], and reports on late sequelae also are rare. Late deterioration may develop as the ventricles dilate or function becomes impaired, as the defect grows, or in the wake of previous tissue damage [2, 7]. In our case we presume the deterioration was brought about by the combination of an increase in pulmonary pressure, a decline in left ventricular compliance, and the onset of atrial fibrillation [8]. We conclude that survivors of gunshot wounds of the heart should be evaluated later for valve lesions, septal defects, and other hemodynamic pathology.
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References
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- Symbas P.N., DiOrio D.A., Tyras D.H., Ware R.E., Hatcher C.R. Penetrating cardiac wounds. J Thorac Cardiovasc Surg 1973;66:526-532.[Medline]
- Sugg W.L., Rea W.J., Ecker R.R., Webb W.R., Rose E.F., Shaw R.R. Penetrating wounds of the heart: an analysis of 459 cases. J Thorac Cardiovasc Surg 1968;56:531-545.[Medline]
- Tavares S., Hankins J.R., Moulton A.L., et al. Management of penetrating cardiac injuries: the role of emergency room thoracotomy. Ann Thorac Surg 1984;38:183-187.[Abstract]
- Ivatury R.R., Rohman M., Steichen F.M., Gunduz Y., Nallathambi M., Stahl W.M. Penetrating cardiac injuries: twenty-year experience. Am Surg 1987;53:300-317.
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- Borow K.M., Alpert J.S., Braunwald E. Congenital heart disease in the adult. In: Braunwald E., ed. Heart disease. Philadelphia: Saunders, 1984:1027-1034.
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Abstract
Introduction
