Traumatic ventricular septal defect: a case report

Injury(1984) 16, 21-22

Traumatic

Printed in Great Britain

ventricular

21

septal

defect:

a case report

W. H. Allum The County

‘Hospital,

Hereford

Summary

A case of traumatic illustrate condition.

ventricular septal defect is reported to the important clinical features of this uncommon

INTRODUCTION

TRAUMATICventricular septal defect is a rare form of closed myocardial injury. Previous reports indicate that it is either rapidly fatal (Parmley et al., 1958) or is not clinically apparent until some time after the injury and can therefore be repaired by an elective operation

(Mackintosh and Fleming, 1981). However, Clark et al. (1974) have described a case which was repaired successfully within 30 hours of injury. This report describes a patient seen soon after injury, to illustrate the clinical features in the hope that similar cases will be diagnosed and considered for early surgical repair. CASE REPORT

A healthy 6-year-old girl fell from a horse and landed on a stone, striking the front of her chest. Initially she was conscious. Shortly afterwards she had a convulsion and became

Fig. 1. Photograph of the heart to show the defect in the apex of the interventricular

septum.

22 unconscious for a few minutes. On examination at a nearby cottage hospital she was drowsy, with a blood pressure of 105/70 and a pulse rate of 90 beats/min. She was transferred to the County Hospital, Hereford, and on admission was pale, centrally cyanosed and had marked orthopnoea. There was bruising over the sternum. Arterial blood pressure was unrecordable and she had a tachycardia of 140 beats/min. A pansystolic murmur, without radiation, was heard at the left sternal edge. Respiratory movements were equal on both sides but air entry was reduced on the left posteriorly. Examination of the abdomen did not reveal any abnormality. There were no localizing neurological signs. Xray films of the chest showed a normal cardiac outline with no bony injury. There was shadowing in the left lung field consistent with pulmonary contusion. A single lead electrocardiogram showed no gross abnormality. In view of her severely hypotensive state she was treated with intravenous saline and then a plasma expander. Oxygen was given by mask. Despite these measures she remained hypotensive and her neck veins became distended. Her respiratory distress increased and intermittent positive-pressure ventilation was instituted via an endotracheal tube. The suspicion of right heart failure was confirmed when her central venous pressure was estimated at + 17 cm H,o. It was thought likely her cardiac failure was secondary to cardiac tamponade with an underlying myocardial injury. She therefore underwent exploratory left thoracotomy. There was no obvious pulmonary injury. There was no blood in the pericardial cavity and the anterior surface of the heart looked essentially normal. Laparotomy was also performed to exclude intra-abdominal haemorrhage. The liver was grossly engorged but there was no other abnormality. Despite intensive attempts to maintain cardiac output the patient died shortly after operation, 7 hours after injury. Examination post mortem showed extensive bruising over the anterior surface of the heart with a 2.5cm rupture in the apex of the interventricular septum (Fig. 1). Bilateral pulmonary congestion and cerebral oedema were also present.

Injury: the British Journal

of Accident

Surgery (1984)

Vol. 1 ~/NO. 1

COMMENT

The case described illustrates well the progressive and severe cardiogenic shock seen in acute traumatic ventricular septal defects. Diagnosis may be aided by electrocardiography with evidence of anterior or anteroseptal myocardial infarction (Clark et al., 1974). Arrhythmias are uncommon as the defect usually occurs at the apex of the septum and so avoids the main conduction system (Liedtke and DeMuth, 1973). Definitive diagnosis can be made by cardiac catheterization to measure the intracardiac pressures and assess the left to right shunt. In patients with large defects and correspondingly large shunts, as in this case, the outcome is usually fatal (Rotman et al., 1970). Acknowledgement I wish to thank Mr C. J. C. Renton for permission to

report this case and for his help in preparation text.

of the

REFERENCES

Clark T. A., Corcoran F.H., Baker W.P. et al. (1974) Early repair of traumatic ventricular septal defect. J. Thorac. Cardiovasc. Surg. 67, 121.

Liedtke A. J. and DeMuth W. E. (1973) Non penetrating cardiac injuries: a collective review. Am. Heart J. 86, 687. Mackintosh A. F. and Fleming H. A. (1981) Cardiac damage presenting late after road accidents. Thorax 36, 811. Parmley L. F., Manion W. C. and Mattingly T. W. (1958) Non penetrating injury to the heart. Circulation 18, 371. Rotman M., Peter R. H., Sealy W. C. et al. (1970) Traumatic ventricular septal defect secondary to non penetrating chest trauma. Am. J. Med. 48, 127. Paper accepted 10 October 1983.

Requestsfor reprintsshouldbe addressed IO:Mr W. H. Allum, Honorary Research Fellow, Department of Surgery, Queen Elizabeth Hospital, Birmingham.