Ann Thorac Surg 1999;67:843-844
© 1999 The Society of Thoracic Surgeons
Case Reports
Isolated fracture of the ventricular septum after blunt chest trauma
Roland B. Schaffer, MDa,
Pascal A. Berdat, MDa,
Christian Seiler, MDb,
Thierry P. Carrel, MDa
a Clinic for Thoracic and Cardiovascular Surgery, University Hospital, Berne, Switzerland
b Department of Cardiology, University Hospital, Berne, Switzerland
Accepted for publication August 31, 1998.
Address reprint requests to Dr Carrel, Clinic for Thoracic and Cardiovascular Surgery, University Hospital, CH-3010 Berne, Switzerland
e-mail: thierry.carrel{at}insel.ch
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Abstract
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Isolated rupture of of the ventricular septum after blunt chest trauma is a very rare traumatic affection. A 21-year-old man was admitted to our hospital because of blunt chest trauma and a forearm fracture. Initial echocardiography did not show any intracardiac or extracardiac pathologic lesions, but 12 hours later this examination was repeated because of the onset of a holosystolic murmur. An unusual traumatic rupture of the ventricular septum was demonstrated. The hemodynamically stable condition of the patient allowed surgical repair to be performed 3 months later.
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Introduction
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The delayed traumatic fracture of the interventricular septum after a blunt injury to the chest is a very rare traumatic affection. Mechanisms involved in the pathogenesis of this affection include an acute compression of the heart between the sternum and the spine, leading to excessive changes in the intrathoracic and probably also the intracardiac pressure.
A 21-year-old man was admitted to our hospital because of blunt chest trauma after a military jeep rolled over him. Initial clinical examination in the emergency station revealed contusion of the face, a forearm fracture, and a bilateral stable serial rib fracture. Chest X-ray film showed bilateral lung contusion with hemothorax on the left side, which was drained soon after. Auscultation of the heart and electrocardiographic results were normal. Blood analysis showed elevated heart-specific enzymes: Creatine kinase was 1,310 U/L (normal value < 190 U/L), creatine kinase-MB mass fraction was 231.7 µg/L (normal value < 4.0 µg/L), and troponin was as high as 30.9 µg/L (< 0.6 µg/L). These values suggested the presence of cardiac contusion, but initial echocardiography showed no intracardiac or extracardiac pathologic lesions and the global and segmental contractility of both ventricles was normal. There was no pericardial fluid at this time. The initial course was uneventful, but 12 hours later a harsh 4/6 holosystolic murmur with punctum maximum over the third and forth left intercostal space appeared, accompanied by a thrill palpable in the same area. The echocardiographic examination was repeated immediately thereafter and showed a large traumatic rupture of the interventricular septum with a significant left-to-right shunt (pulmonary–systemic blood flow ratio, 2.7) (Fig 1). At this time, the patient did not show any signs of heart failure, and owing to his stable hemodynamic condition he was treated conservatively. An echocardiographic follow-up examination 1 week later showed no further enlargement of the ventricular septal defect and a constant shunt with slight dilation of the right ventricle with moderate pulmonary hypertension. Because the patient remained hemodynamically stable, immediate surgical intervention did not appear to be mandatory, thus definitive surgical treatment was deferred for 2 to 3 months. Six weeks later, the patient complained of reduced exercise tolerance with mild exertional dyspnea. Surgical repair was finally performed 2 months after the initial trauma. Cardiopulmonary bypass was conducted with mild hypothermia after aortic and bicaval cannulation. Exploration of the interventricular septum was first tried through the right atrium and the tricuspid valve to avoid ventriculotomy. Precise identification of the rupture was difficult because of excessive trabeculation and the tunnel-like configuration of the defect. A large patch of polytetrafluoroethylene was used to cover the defect, and interrupted polypropylene 4.0 sutures were placed. Transesophageal echocardiography at the end of the operation showed a bulging of the patch on the right side, with a persistent defect at the inferior suture line (Fig 2). Left ventriculotomy was then performed, and the size of the rupture was exposed without difficulty from the apex of the left ventricle. A 0.6-mm Gore-Tex patch (W. L. Gore & Assoc, Flagstaff, AZ) was sutured with continuous running polypropylene 4.0 sutures to cover the defect. The borders of the defect were very fibrotic, a condition that considerably facilitated the suturing technique. The left ventricle was closed directly without Teflon felt, and the patient could be weaned from extracorporeal circulation in sinus rhythm and without inotropic support. Transesophageal echocardiography confirmed complete closure of the septal defect (Fig 3). Postoperative electrocardiography did not demonstrate any bundle branch block or any other arrhythmia, and the patient was discharged on postoperative day 7.
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Fig 1. Echocardiogram showing large traumatic rupture of the interventricular septum with a significant left-to-right shunt 12 hours after injury. (LV = left ventricle; RV = right ventricle; VSD = ventricular septal defect.)
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Fig 2. Transesophageal echocardiogram showing bulging of the patch on the right side with a persistent defect at the inferior suture line. (LV = left ventricle; RV = right ventricular.)
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Fig 3. Postoperative transesophageal echocardiogram showing complete closure of the septal defect. (LA = left atrium; LV = left ventricle, left ventricular; RV = right ventricle, right ventricular.)
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Comment
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Cardiac contusion is the most frequent lesion of the heart observed after blunt chest trauma. This affection shows a good prognosis; sometimes a Dressler syndrome develops. Serious blunt injuries to the heart, followed by rupture of the ventricles or atria, lead to instantaneous pericardial tamponade and death, usually before hospital admission. In our patient, isolated traumatic rupture of the ventricular septum occurred with delay because the murmur appeared only 12 hours after admission, and initial echocardiography did not show any shunt through the septum. This type of lesion is very rare and is thought to be due to heart compression between the sternum and the spine, resulting in extreme changes in intrathoracic as well as intracardiac pressure during sudden deceleration. Traumatic rupture of the interventricular septum is more likely to occur in late diastole and early systole, the septum near the apex being the most common site of rupture [1]. Multiple rupture sites have been reported as well as concomitant injury of the conduction system [2]. Usually the patient is acutely ill from the coexisting myocardial injury and lung trauma. Symptoms are similar to those seen in postinfarction ventricular septal defect, with dyspnea, anxiety, chest pain, or other signs of cardiac failure. Diagnosis is established by transthoracic or transesophageal echocardiography, which allows other intracardiac lesions to be ruled out [3]. In the present case, the delay between the accident and the appearance of the traumatic ventricular septal defect was probably due to the very unusual pattern of the ventricular septal defect. It might be that an initial small traumatic tear in the septum led to secondary total disruption, favored by contusion and weakening of the septal myocardial tissue. Surgical closure is the treatment of choice and should be timed according to the patient’s hemodynamic condition. In our patient, definitive surgical repair could safely be deferred for 2 months. Closure of the defect was realized with a prosthetic patch of Gore-Tex material; a glutaraldehyde-fixed xenopericardial patch would have been an alternative choice. In the present case transatrial closure was rendered difficult because of the tunnel-like configuration of the rupture; in such cases, a left ventricular approach is recommended. In view of the aspect of the defect, interventional closure using a device was not considered to offer a promising result.
The present report illustrates that traumatic rupture of the interventricular septum can appear clinically with a certain delay after blunt chest trauma. Definitive surgical treatment can be postponed in hemodynamically stable patients, and delayed operation is greatly facilitated by fibrous tissue, which usually develops at the rim of the defect.
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References
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Evora P.R.B., Ribeiro P.J.F., Brasil J.C.F., et al. Late surgical repair of ventricular septal defect due to nonpenetrating chest trauma: review and report of two contrasting cases. J Trauma 1985;25:1007-1009.[Medline]
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End A., Rodier S., Oturanlar D., et al. Surgery of blunt heart trauma. Chirurg 1992;63:641-646.[Medline]
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Cabrera A., Velasco J.V., Idigoras G., et al. An imaging and color echo-Doppler study of interventricular defects. Rev Esp Cardiol 1993;46:721-726.[Medline]
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Abstract
Introduction
