Interactive Cardiovascular and Thoracic Surgery 2 (2003) 84–86 www.icvts.org
Case report – Cardiac general
Delayed diagnosis of a post-traumatic ventricular aneurysm? Marcin Dada 1, Luc Noyez*, Freek W.A. Verheugt, Rene M.H.J. Brouwer Department of Thoracic and Cardiac Surgery, Heart Center, University Medical Center Nijmegen, St. Radboud, Nijmegen, The Netherlands Received 8 October 2002; received in revised form 17 November 2002; accepted 19 November 2002
Abstract A 52-year-old man was developed pleural effusion and congestive heart failure after a routine orthopedic operation. A compression of atrium and right ventricle, by a calcified mass was discovered. The patient remembered having a blunt chest trauma 34 years before. We believe that the mass, an old hematoma, which was resected, was the result of on occult post-traumatic ventricular aneurysm. q 2002 Elsevier Science B.V. All rights reserved. Keywords: Ventricular; Trauma; Aneurysm; Diagnosis
1. Introduction Non-penetrating trauma of the chest can result in severe damage to the heart. In some patients these injuries result in extreme symptoms, and in some they may be occult [1]. We describe the case of a patient who presented with a posttraumatic ventricular aneurysm 34 years after the trauma.
2. Case report A 52-year-old man, in excellent health, was operated on for a lesion of the tendon calcaneus (Achilles tendon). Postoperatively he developed pleural effusion and congestive heart failure. His medical antecedents were negative, with exception of a meniscetomy, 10 years before. Chest film showed a normal view of the mediastinum, and some retrocardial calcifications, also visible on a chest film of 10 years earlier. Examination of the pleural effusion was negative for infection as well as for cytology. Echocardiography (transthoracal and esophageal) showed a normal left ventricle (LV), compression of right ventricle (RV) and right atrium (RA), by a calcified mass, without flow. Flow over the mitral and tricuspid valve was suggestive for a constriction. Computed tomography (CT) scan showed a calcified mass, compression of RV and RA (Fig. 1). The left side of the
* Corresponding author. Tel.: 131-24-361-4744; fax: 131-24-354-0129. E-mail address:
[email protected] (L. Noyez). 1 Medical student, University of Lodz, Lodz, Poland.
heart showed no abnormality. Coronary arteriography revealed normal coronary arteries. Hemodynamic data: RA pressure 20 mmHg, RV pressure 40/5–20 mmHg, LV pressure 105/0–70 mmHg, aortic pressure: 110/70 mmHg, pulmonary artery pressure 33/24 mmHg with a wedge pressure of 23 mmHg; cardiac output: 5.3 l/min. Later the patient told us having been involved in a car accident at the age of 18 years. He remembered that he had suffered chest pain. However, after 1 day of bed rest in a hospital, he was discharged. An operation was performed. After sternotomy, the calcified mass proved to be adherent to and compressing the right ventricle, and atrium was identified. The mass was opened, and a putty mass, the old hematoma, was extracted. The calcified wall was resected from the greater part of the right ventricular and atrial wall, and both caval veins were freed from this calcification. No ‘neck’ or place of entry could be located. There was no drop in central venous pressure. Pathology confirmed the diagnosis of ‘old hematoma’. The postoperative course was uneventful. Echography performed 10 days postoperatively showed no compression of the right ventricle and atrium, and the flow over the tricuspid and mitral valves was normal. Six months postoperatively, the patient was in good health, and had returned to work and taking part in sport (better than before).
3. Discussion With the increase in high-speed motor vehicle accidents, blunt cardiac trauma is seen more frequently. An early review of non-penetrating cardiac trauma indicated that
1569-9293/02/$ - see front matter q 2002 Elsevier Science B.V. All rights reserved. doi:10.1016/S 1569 -92 93(02)00108-1
M. Dada et al. / Interactive Cardiovascular and Thoracic Surgery 2 (2003) 84–86
Fig. 1. Computed tomography scan showing the intrapericardial calcified mass (arrow), with compression of the right ventricle.
only 33% of blunt injuries resulted from automobile accidents. Nowadays this has increased to about 80% [1,2]. The mechanism of blunt cardiac trauma is of two kinds [1]: compression between sternum and the vertebral column, or a sudden deceleration of the chest resulting in a thrust forward of the heart against the sternum. Consequently the intracardiac, particularly intraventricular, pressure becomes high and the free wall, the ventricular septum, or cusps of the aortic valve may rupture. The type and extent of blunt cardiac injuries vary widely (Table 1) [1–4]. Right ventricular myocardial contusions occur most often because of the position of heart in the chest, but left ventricular aneurysms develop more frequently because of the higher intracavitary pressure. Clinically, blunt cardiac injuries can be divided into
Table 1 Types of cardiac injury after blunt chest trauma Myocardium Contusion Laceration Rupture Dissection Aneurysm Ventricular septal defect Cardiac valves Aortic insufficiency Mitral insufficiency Tricuspid insufficiency Coronary arteries Thrombosis Laceration Fistula Pericardium Hemorrhage Effusion Laceration Cardiac herniation
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significant and insignificant injuries [1]. Cardiac rupture, valvular dysfunction and coronary thromboses are clinically significant injuries. These injuries present as tamponade hemorrhage or severe cardiac dysfunction. Some of them may initially present without symptoms, but present later as delayed sequelae, such as dysrhythmias, or heart failure as consequence of a minor valvular dysfunction. Ventricular aneurysm is an uncommon complication of blunt chest trauma. However, its true incidence is unknown because it is probably underdiagnosed [1]. Three mechanisms have been described for the formation of myocardial post-traumatic aneurysms: contusion, vascular lesions leading to myocardial necrosis, and myocardial dissection [1–4]. The term aneurysm is generally reserved for a dyskinetic area of the ventricular wall with a broad neck to differentiate it from pseudoaneurysm, due to contained myocardial rupture. The overlying pericardium is usually densely adherent to the ventricular wall. The aneurysm frequently contains thrombus, and the wall may become partially calcified after several years and is sometimes difficult to differentiate from old hematomas [1,2]. Also in our case we have no proof of a real aneurysm. However, in the case of an old hematoma, we can suppose that at the moment of the trauma, there had to be massive bleeding, which is not suggestive regarding the history of the patient. Congestive heart failure is the most common presenting symptom, but also arrhythmias and arterial embolus are described. Many of these patients have only mild complaints, such as weakness and malaise, but some patients are asymptomatic. The time from injury to diagnosis mostly ranges between 5 days and 20 years [1–5]. Surgical resection of the aneurysm in symptomatic patients is logical. In asymptomatic patients it is controversial. Because of the low risk of the operation and the good prognosis following resection, surgery is preferred [1,2]. In our patient, there were 34 years between trauma and diagnosis, and probably the hemodynamic equilibrium, which he developed over the years, was disturbed during the perioperative period of the Achilles tendon operation, resulting in a period of congestive heart failure. The echocardiogram, showing a normal left ventricle, compression of the right atrium and ventricle with a flow patterns over mitral and tricuspid valve suggestive for constriction, and the CT scan showing no involvement of the left ventricle in the process, suggest that the aneurysm originated from right ventricle. With this case report we would like to draw attention to the possibility of insignificant cardiac injuries due to blunt chest trauma with a delayed presentation of symptoms. References [1] Braunwald E. Heart disease, Philadelphia, PA: Saunders, 2001. pp. 1177–1186. [2] Moylan JA. Trauma surgery, Philadelphia, PA: Lippincott, 1998. pp. 153–169.
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[3] Grieco JG, Montoya A, Sullivan HJ, Bakhos M, Foy BK, Blakeman B, Pifarre´ R. Venticular aneurysm due to blunt chest injury. Ann Thorac Surg 1989;47:322–329. [4] Maselli D, Micalizzi E, Pizio R, Audo A, De Casperis C. Posttraumatic left ventricular pseudoaneurysm due to intramyocardial dissection hematoma. Ann Thorac Surg 1997;64:830–831. [5] Jordan J, Dietz R. Traumatic ventricular aneurysm. N Engl J Med 1997;336:625.
Appendix A. ICVTS on-line discussion Author: Dr. Christof Stamm, University of Rostock, Cardiac Surgery, Schillingallee 35, D-18057 Rostock, Germany Date: 20-Dec-2002 08:06 Message: The authors present a remarkable case that nicely illustrates the typical long-term consequences of undiagnosed blunt trauma to the heart. We would like to add that children are at particularly high risk of cardiac injury following blunt chest trauma, because the flexible rib cage facilitates compression of the heart between the anterior and posterior chest wall. For instance, we have reported a case of a 13-year-old boy who developed LV aneurysm and VSD several days following an otherwise uncomplicated motorcycle accident, and who was diagnosed in time thanks to the vigilance of his mother (Eur J Cardiothorac Surg. 2002;22:154-6). We believe that in every case of suspected or confirmed blunt chest trauma, especially in children, echocardiography should be performed at the time of admission, after an interval of 1-2 weeks, and once again after several months.
Author: Dr. Moheb Rashid, Copenhagen University Hospital “Rigshospitalet”, Cardiothoracic Surgery, Hagforsgatan 71, Gothenburg, 416 75, Sweden Date: 15-Jan-2003 19:16 Message: It was interesting to read this case report and the comment by Dr. C. Stamm, which I’m concerned with. Echocardiography is definitely an ideal diagnostic tool for evaluating patients with cardiac injuries. When the transthoracic approach (TTE) is suboptimal, then a transesophageal echocardiography (TEE) is of value. Here I’m just commenting on the optimal time to perform TTE or TEE which is a matter of individual decision making that varies greatly from patient to patient. This was a suitable investigation at the proper time just in your patient who developed LV aneurysm and VSD several days following trauma. I think it is hard to recommend a schedule for TTE and/or TEE in patients with trunk trauma, aiming at not to miss a cardiac lesion. Such an examination should be carried out whenever indicated from the time of trauma and as long as the patient is surviving, as the literature witnesses so many cases with cardiac lesions diagnosed several hours, days, weeks and years after trauma. However, in our Scandinavian experience; screening using TTE and/or TEE for patients with cardiac trauma is not of value as the majority of patients with myocardial contusion remain asymptomatic and have favourable results. The clinical examination depicting one or more components of Beck’s triad (may be deceptive) was found in all patients with cardiac injuries confirmed at operation. On the other hand, TTE and/or TEE performed by experienced echocardiographers were not positive in all patients with documented heart injuries during surgery.
