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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 154-156

Dissection of the interventricular septum after compressive blunt chest trauma


1 Day Medical Tower, Shaheed Rajaei Heart Center, Iran University of Medical Science, Iran
2 Department of Adult Congenital Heart Disease, Shaheed Rajaei Heart Center, Iran University of Medical Science, Iran
3 Department of Echocardiography, Shaheed Beheshti Hospital, Qhom University of Medical Science, Qhom, Iran

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Bahieh Moradi
Day Medical Tower, Vali.Asr Ave., Second Gandy Alley, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_8_18

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  Abstract 


We report the case of a 21-year-old woman who was referred after a severe compressive blunt trauma in the context of job injury. Myocardial contusion is a common injury; however, rupture of the ventricular septum after blunt chest trauma is a rare event. Echocardiography revealed a large ventricular septal rupture with two small ventricular septal defects. The patient was a candidate for surgical repair after early conservative management. We discuss about the prevalence and management of this rare traumatic complication.

Keywords: Blunt chest trauma, posttraumatic ventricular septal defect, ventricular septal rupture


How to cite this article:
Moradi B, Khajali Z, Moradi S, Nazeri A. Dissection of the interventricular septum after compressive blunt chest trauma. Res Cardiovasc Med 2018;7:154-6

How to cite this URL:
Moradi B, Khajali Z, Moradi S, Nazeri A. Dissection of the interventricular septum after compressive blunt chest trauma. Res Cardiovasc Med [serial online] 2018 [cited 2018 Dec 17];7:154-6. Available from: http://www.rcvmonline.com/text.asp?2018/7/3/154/240993




  Introduction Top


Ventricular septal ruptur (VSR) after blunt chest trauma is a very rare traumatic affection. It was first described by Hewett in 1847.[1] VSR is believed to have occurred due to the compression of the chest, whereas the ventricles are filled, and the atrioventricular valves are closed, resulting in excessive intraventricular pressure.[2] Although early diagnosis is infrequent because the condition is disregarded, echocardiography can help to diagnose pericardial effusion, myocardial dyskinesia, valvular dysfunction, or other more rare injuries.[3]


  Case Report Top


Medical history

A 21-year-old female factory worker, with no relevant history, was referred from a trauma center to our hospital 8 days after a severe compressive blunt chest trauma and rib fracture.

Physical examination

Initial clinical examination in the emergency room revealed hemodynamically stable condition with cannon A wave in jugular venous pressure, rough breath sounds, contusion of the chest wall, and rib fracture. She had bilateral chest tubes because of hemopneumothorax, and auscultation of the heart revealed a III/IV harsh holosystolic murmur with maximal intensity in the third left intercostal space, accompanied by a thrill palpable in the same area. Abdominal examination showed no liver enlargement, normal bowel sounds, no tenderness, or guarding. Pulses were normal.

Laboratory tests

The electrocardiogram (ECG), chest radiograph, and echocardiogram are shown in [Figure 1], [Figure 2], [Figure 3]. Blood analysis showed cardiac enzymes within normal limits and mildly increased troponin. Chest X-ray showed no additional finding. The ECG showed that narrow complexes complete heart block. Echocardiographic evidence showed a large dissecting rupture of the ventricular septum equal to 1.5 cm with two small-sized defects (6 and 4 mm) at the proximal side of dissection and significant left to right shunt (Qp/Qs = 1.9), good left ventricular ejection fraction equal to 55%, mild right ventricular enlargement and good function, mild pulmonary arterial hypertension (pulmonary artery pressure = 40 mmHg), and mild tricuspid regurgitation, with no pericardial effusion. On three-dimensional echo, we found some connection between two parts of septum by muscle bands. The patient had been a candidate for surgical repair.
Figure 1: Resting electrocardiogram showing sinus rhythm, normal axis, no overload, no progression of R-wave, and permanent T-wave inversion in V1–V2, narrow complex complete heart block

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Figure 2: Chest radiograph showing cardiac silhouette with normal diameters, Grade 4/4 increased pulmonary blood flow

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Figure 3: Transthoracic echocardiography. (a) Large ventricular septal rupture with diameter equal to 1.5 cm in upper septum (arrow), (b) continuous wave Doppler shows left-to-right shunt pattern

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  Discussion Top


Incidence

The most common cardiac injuries after blunt chest trauma are cardiac contusion, valvular damage, and aortic insufficiency due to a tear in the aortic cusp or avulsion of a commissure. VSR is a rare complication following nonpenetrating chest trauma.[3] The real incidence of VSR following chest trauma remains unknown in the literature. However, previous publications analyzing autopsies of more than 20,000 cases of death secondary to car accidents identified VSR in 0.01% of the cases, and in only 0.002%, the defects were isolated. Rupture of the free ventricular wall was the most common form of presentation among these cases.[1]

Mechanisms

VSR may be the consequence of several factors resulting from the interaction between forces that act on the cardiac structures at the moment of the impact. The cardiac injury could be resulted from direct and/or indirect action forces, bidirectional or compressive forces, deceleration, explosive forces, concussion, and combination of the previous.[1],[2] Cardiac injuries may be more common in the absence of broken ribs or sternal lesions, particularly in younger patients with a less rigid chest wall.[3] The compression exerted by the rib cage on the heart, more specifically between the sternum and the thoracic column, resulted in sudden increase in the intracardiac pressure during late diastole or isovolumetric systole. During this period, the chambers are full and the valves are closed, immediate relief of the inner pressure is impossible and thus resulting in genesis of myocardial contusion and rupture. However, coronary lesion secondary to contusion is another possible mechanism and could account for the cases with late clinical presentation, as a consequence of infarction, local necrosis, and further muscle rupture.[1] Since our patient had been trapped between factory machines, the responsible mechanism was combination of direct and bidirectional compressive forces in the presence of rib fracture and pulmonary contusion.

Diagnostic approach

To facilitate the diagnosis, a high index of clinical suspicion is necessary, aiming primarily at preventing the potential lethal consequences of the ventricular rupture. Several methods such as ECG, enzyme markers, myocardial perfusion scintigraphy, and echocardiography (whether conventional or three dimensional) are currently available.

Electrographic alterations are unspecific for contusion and include ST-segment and T-wave abnormalities. Ventricular and atrial arrhythmias may be present, and atrioventricular block is hardly ever reported. The clinical presentation may be acute, subacute, or late, depending on the extension of the injury and subsequent local necrosis. The cardiac murmur may be detected in the initial presentation, or in the majority, it may become apparent between 4 and 12 days,[1] and clinical course is varying from immediate death to complete spontaneous closure. Therefore, closed observation is essential for the management of these patients.[1],[2] Symptoms are very wide ranging. There may be asymptomatic cases, chest pain, dyspnea, palpitation, or more severe presentations with progressive heart failure, cardiogenic shock, and death.[1] The clinical presentation chest pain and painful breathing without progressing to dyspnea or overt heart failure is worth noting in the present case.

In the present case, four reasonable elements which justified a traumatic etiology for the septal defect include the negative past medical history for cardiac symptoms, recalling the nature of the patient's professional activity, no signs of ventricular overload in the ECG, and chest radiograph showing a normal cardiac silhouette – incompatible with the extension of the VSR found in the echocardiogram. These data suggest that the likelihood of this patient to have congenital septal defect until adolescence without being diagnosed is very remote.

Management

In general, early surgical closure is the treatment of choice and should be timed according to the patient's hemodynamic condition. Some experts recommend conservative approach for asymptomatic cases because the margins of the defect undergo fibrotic changes and this provides an easy and safe suture line.[4] However, in case of a large unrestrictive interventricular communication, homodynamic decompensation develops more rapidly [2],[3],[4],[5] and early invasive approach is recommended.[2],[5] In this case, we chose an early conservative management because of the patent's stable clinical course and hemodynamic status, and we decided to wait several weeks to allow a regression of the pulmonary contusion and septal fibrosis, to ensure safer suture conditions. A sequence of echocardiography during a 20-day stay in the hospital showed no change in the extent of septal rupture, chambers' size, systolic function, shape of the left ventricle, and shunting through the rupture. Reevaluation was planned after 6 weeks of medical observation.


  Conclusion Top


VSR is a very rare complication following blunt chest trauma. Once cardiac injury is suspected, structural damage should be overruled using immediate clinical assessment and closed observation with repeated diagnostic techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mello R, Santana M, Paula Silva M, Esteves C, Pedra C, Thom A, et al. Rupture following blunt chest trauma. Arq Bras Cardiol 2006;87:e168-71.  Back to cited text no. 1
    
2.
Sabzi F, Niazi M, Zokaei AH, Sahebjamee F, Bazargan Hejazi S, Ahmadi A, et al. Ventricular septal necrosis after blunt chest trauma. J Inj Violence Res 2012;4:98-100.  Back to cited text no. 2
    
3.
Hamdan-Challe M, Godin M, Bouchart F, Doguet F. Isolated ventricular septal rupture secondary to blunt trauma. Interact Cardiovasc Thorac Surg 2010;11:667-9.  Back to cited text no. 3
    
4.
Stamm C, Feit LR, Geva T, del Nido PJ. Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma. Eur J Cardiothorac Surg 2002;22:154-6.  Back to cited text no. 4
    
5.
Tarmiz A, Lopez S, Honton B, Riu B. Surgical repair of rupture of the membranous septum after blunt chest trauma. Ann Thorac Surg 2011;91:e3-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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