Traumatic ventricular septal defect after a kick by a cow

Pediatr Cardiol 15:238-240, 1994

Pediatric Cardiology 9 Spdnger-VerlagNew York Inc. 1994

Case Reports T r a u m a t i c V e n t r i c u l a r Septal D e f e c t After a K i c k by a C o w V. Nedeljkovi6,1 J. Jablanov, 2 J. Ko~uti6,1 and B. Miomanovi61 ~Department of Cardiology, Mother and Child Health Institute, and 2Department of Surgery, Military Medical Academy, Beograd, Yugoslavia

SUMMARY. A case is presented of an unusual rupture of the ventricular septum due to a kick from a cow. The 7-year-old boy developed acute cardiac failure. The electrocardiogram showed anterior and apical myocardial infarction. Two-dimensional color and Doppler echocardiography revealed a rupture of the ventricular septum. The traumatic ventricular septal defect was successfully closed using a right atrial approach. KEY WORDS: Echocardiography m Myocardial infarction m Surgical repair - - Traumatic ventricular septal defect

Rupture of the ventricular septum (VS) by nonpenetrating trauma is rare during childhood [1, 4]. It may occur as a complication of infective endocarditis, closed chest massage [2, 4], penetrating trauma [4] of myocardial infarction (incidence in adults 1%) [1, 2]. To our knowledge this is the first report of rupture of the VS resulting from a kick by a cow.

Case Report On July 1991 a previously completely healthy 7-year-old boy was kicked by a cow and knocked down. He felt a sharp pain in the chest and lost consciousness for 4-5 min. He was admitted to the intensive care unit. On admission the boy, who weighed 25 kg, was pale, tachypneic, and tachycardic but had stable vital signs. There was no wound on his chest or body. The cardiac sounds were dull and a pansystolic murmur grade 416 was heard along the left sternal border. Electrocardiographic and radiographic findings were within normal limits. After 24 h he developed congestive cardiac failure with gallop rhythm, dull sounds, and systolic and diastolic murmurs on the mitral and tricuspid valves. Blood pressure ranged from 75/48 to 100/61 mmHg. The liver was enlarged and ultrasonog-

Address offprint requests to: Professor Dr. Vladislava Nedeljkovif, Mother and Child Health Institute, 8 Radoja Dakifa, 11071 Novi Beograd, Yugoslavia.

raphy revealed a small intraabdominal effusion. The electrocardiogram showed anteroapical myocardial infarction: a small R wave in V~, V2, and V4; and absent R wave in V3; an elevated ST in V1-V4, and a low T wave in Vs/6 c (Fig. 1). After 10 days the ECG revealed ischemic changes: a negative T wave in D~ and V4-V 6. The chest radiograph showed cardiomegaly with pulmonary edema. Two-dimensional echocardiography showed atrioventricular and ventriculoarterial concordance, an enlarged right ventricle, and tricuspid regurgitation of 4 m/s. There was a ventricular septal rupture. The parasternal long-axis and apical fourchamber views from the left ventricular side revealed a midmuscular ventricular septal defect (VSD) of 16 mm with muscle destruction; from the fight ventficular side the VSD was 8-10 mm. Continuous-wave Doppler echocardiography showed a leftto-fight shunt of 4 m/s with a pressure gradient of 64 mmHg; right ventricular pressure was about 60 mmHg. Laboratory investigations showed the hemoglobin to be 120-80 g/L, red blood cell count 4.4 • 1012 to 3.3 • 1012, hematocrit 0.44-0.34%, and the white blood cell count 10.2 • 10 9 to 20.5 • 109/L. The transaminase units were 46 (normal 25) for SGOT and 50 (normal 35) for SGPT. Lactic dehydrogenase was increased to 665 (normal 399); creatine phosphokinase was within normal limits. Values for Serum electrolytes, arterial oxygen saturation, pH, and base deficit were within the normal range. Twenty-three days after the accident the boy's condition was fairly stable, and he underwent an operation in which the ruptured ventricular septum was successfully closed by the tricuspid approach. Postoperatively the patient's condition improved greatly. The electrocardiogram and the radiographic appearance of the heart were within normal limits. A systolic ejection murmur (grade 3/6) remained, presenting over the IV-V left intercostal space with normal sounds and rhythm. Blood pres-

Nedeljkovid et al.: Traumatic VSD After a Kick by a Cow

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Discussion I

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Fig. 1. Electrocardiogram on admission showing anteroapical infarction. The R wave is small in V1 and V2 and absent in V3: there is elevation of the ST segment in leads V 1 through V 4.

sure was 110/65 mmHg. All laboratory dma were within the normal range. The echocardiogram showed a normal right ventricular size and ejection fraction of the lef'L ventricle (39%). Continuous-wave and pulsed-wave Doppler echocardiography showed normal flow through the tricuspid valve, mitral valve, and pulmonary artery. From the right ventricular side, on and below the moderator band, a patch was seen that color Doppler revealed to be a small left-to-right shunt. On the left ventricular side a defect of 8 mm was seen in the VS, Ten months after the operation the boy was in good condition and functioned as a healthy child without cardiovascular problems. Physically there was a short systolic murmur (grade 2-3/6) over the left sternal border. Echocardiography showed a defect in the mid-muscular VS from the left ventricular side and a small leak without hemodynamic changes (Fig. 2).

The incidence of severe trauma in children is high but cardiac trauma, especially from nonpenetrating chest injuries is uncommon [1-3]. Various cardiac injuries may occur: myocardial and pericardial contusion or rupture, rupture of valves, chordae tendineae or papillary muscles, and septal perforation [4, 7]. Ventricular septal rupture is rare, comprising 2% of all cardiac lesions [51. The most frequent site of perforation of the VS is near the apex. Injuries to coronary arteries are rare in children [I]. The nonpenetrating trauma reported here is exceptional. The mechanism of injury in our patient can be explained by a forceful blow that resulted in an extreme change in intrathoracic pressure, heart compression, and excessive intraventricular pressure. These events probably happened during late diastole and early systole and resulted in a tension rupture of the VS [4, 7, 8]. The cardiac failure in our patient can be explained by two mechanisms: myocardial contusion and laceration of the VS septum [6]. The myocardial infarction seen on the electrocardiogram was probably the result of myocardial contusion, suggested as well by the laboratory analyses (increased white blood cells. SGOT, SGPT, and lactate dehydrogenase) and the fact that at operation myocardial hemorrhage and suffusion were found on the apex and muscular septum. Rupture of the VS resulted in right ventricular failure due to acute volume overload. Two-dimensional and continuous-wave Doppler echocardiography is the method of choice for visualizing VSD and other lesions, estimating the hemodynamic changes, and making decisions regarding surgical treatment. Furthermore these techniques are ideal for the postoperative evaluation of patients [5, 6]. In our patient surgery was the only way to prevent progressive cardiac failure and deterioration. One year after surgery the boy had normal cardiac functions but a small residual VSD, giving the impression that an aneurysm was still present. Because of the possibility of thrombus formation and infective endocarditis, further measures to prevent endocarditis are needed. References

Fig. 2. (Left) Preoperative echocardiogram (subcostal fourchamber view) clearly showing a huge mid-muscular VSD. (Right) Doppler trace of the flow through the VSD. LV, left ventricle.

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(1982) Communication interventriculaire acquise et faux aneurysme ventriculaire gauche par traumatisme non 15efietrant du thorax. Arch Mal Coeur 76:47-75 7. Pichard LR, Mattox KL, Beall AC (1980) Ventricular septal defect from blunt chest injury. J Trauma 20:329 8. Rotman M, Peter RH, Scaly WC, et al (1970) Traumatic ventricular septal defect secondary to nonpenetrating chest trauma. Am J Med 48:127-131