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False Aneurysm of the Left Ventricle due to a Penetrating Chest Wound
F((a'"~: 3. Sport· of Acli/IOIIIYC('/I'S Ihl'l"'IOJlhilus in ('ytoplasm of a histiocylt' .
this contact was made by breathin~. Tht, second ar~ument for tilt' responsihility of inhaled anti~ens is the demonstration of numerons actinomycetes in the patient's lun~ biopsy specinwn. In CSA. etiolo~ic and prt'cipitatin~ factors art' not dett'rmined in most cases and only rare publications" sUAAest that vaccination or desensitization could ht' factors triAAerin~ the vasculitis. The disease occurs in asthmatic patit'nts and the anti~en responsihle for the respiratory disease conld he inhaled. In other vasculitides such as We~ener's ~rannlo matosis, the occnrrence in patients who had inhaled wood particles advocalt-'s the responsihility of an inhaled anti~en. We snAAt'st, tllt'rt'fore, that inhaled anti~ens should be considered as possihle etiolo~ic factors fill' systemic vasculitis with respiratory manifestations. REFEHENt :ES
I Phannphak I~ Kohcl'r PF. Onst'l of polyarlt'ritis nCKlosa durin~ all....~k- hyposensiti/.ation trt'atml'n\. Am J I\It·d I~: 61i:47H-Ii.'5 2 Guillt'\'in L, Gnillard Til, Bldry 0, Godean P. Rosenthal P. Systemic Ilt'crolizin~ an~iitis with asthma: causI's and predpitatin~ factors in 43 caSt·s. Llln~ IHR7: Hi.'5: Hi.'5-72
False Aneurysm of the Left Ventricle due to a Penetrating Chest Wound* 1':lills 8(/(/ui, M.D., FC'.C.P.; Ros,,/IJt1 M"drid, M.D.; N'nlll/u/o Ayll/II, M.D.; Ho/It'rlo Enciso, M.D.; "1lI/
H"u/ \In/in, M.D.
A 24-year-old white man had a knife chest wound, and four months after this event, manifested progressive dyspnea. A false aneurysm of the left ventricle was diagnosed by 2D echocardiogram. Surgical resection of the aneurysmal sac with closure of the orifice of the lateral wall of the left ventricle was performed successfully. (Chest 1991; 100:1473-74) 4.mon~ tht· heart injuries due to pt'netratin~ chest traumas ~ are those secondary to perforation of tht' pericardinm
*From the Department of Cardiolo!.'Y, Ilospital dt· Especialidades. Centro l\Iedit'l la Raz'l, Institllto l\Iexk-ano d..l Se~uro Social. Mexiw City, Mexit". /U'Jlrinl rr'quI'slS: Dr. 8(/(/ui. 8usqUi' 1/" Gnlll"do.s .521, 8osl/w'.s 1/"
las V.mws, Mexico DF 11700, Mexico
F((;lIKE I. Chest x-ray film in which the cardiothoraci(' ratio (0.60) is increased due to the 11lIIkiness of the perit-ardial sac on the lateral wall of the left ventricle.
aud myocardium in a variety of manners. They include intt'rnal bleedin~ and hemopericardium with or without the development of tamponade. 1.2 In this report. we describe an unusual delayed complication of a penetratin~ wound of the heart manifested as a false aneurysm of the left ventricle. CASE REPOHT
A 24-year-old white male farmer, withont any important past nlt'dit'al history, durin~ a fi~ht received a knife stah wound on the lalt'ral wall of till' left hemithorax in the sixth left interwstal space at Ihe middle 'Lxilar line. The patient received first aid in a primary len'l clink- where a chest tnhe for pneumothorax was installed. After that, the patient apparently rewvered and refused further m'U1a~emen\. IIowever, four months later. he started complain in/.( of pro/.(ressive shortness of hreath for which he was referred to a third level hospital for further work-up. On physk-al examination, the patient was (,mscious and hemodynamically stahle. The hlood pressure was llOno mm II~: re~ular pulse at 100 per minute: respirations, 26 per minute with no fever. Ears. 1I0se, aud throat were normal. Carotid pulses were re~ular hilaterally. No jll/.(ular distention was present. Pulmonary lun~ fields ",('n' clear. Pulse of maximal intensity was localized at the fifth to sixth left interwstal space at the middle davicular line with paradoxic apical impulse. A soft <:ontinuous murmur /.(mde 214 was I"'ard al the ftlllrth left intermstal space at the middle davit'ular lillc. The rest of the physical examinalinn was unremarkahle. Lahoratory results. which included CBC, SMA 12. serum 1'11I.ymes. and eledmlytes as well as urinalysis, were within nnrmal limits. Reslin/.( electrocardio/.(ram shnwed sinus tachycardia, 100 per minute, with suhepicardial ischemia nn the lateral wall nf the left ventricle (LV). Cardiac x-ray series presented an incre'L~ed trallsversal heart diameter at the expense ..f the lateral wall nf the LV Wi/.( I). The M-mode e<:h..cardio/.(ram with Doppler detected a false aneurysm ..f the left ventricle, inside of which several small thmmhi were ohserved, as shown in Fi/.(ure 2. The patient was ..perated on. The false aneurysm ft>rmed by the Silme pericardial sac was resected and the ..rifice of the lateral wall of the LV was d ..sed. He recovered completely without any further mmplications. CHEST I 100 I 5 I NOVEMBER. 1991
1473
FICllRt: 2. A. A four-chamber view 2D echocarwith Doppler showin~ the false aneurysm Hf the left ventricle as is indicated by the arn>w. B. A close-up view Hf the perforated left ventricular wall, thrnu~ which a hidirectional Row was allowed within the LV and the FA durin~ the cardiac cycle. In systole, the FA was filled up, while in diastole. the hlooo Row returned to LV. In addition, the inner wall of the FA wa.s mvered with multiple small thrombi (T). RA is ri~ht atrium; RV. ri~ht ventricle; LA. left atrium. I,V. left ventricle; FA, false aneurysm; • and VAl, mitral valve. dio~ram
J)ISCliSSION Ht'art injuries sl>c(mdary to a penetrating chest trauma are divI'rsl' depeuding upon tht· modI', sight, and size of the lesion, and particularly, the state of the pericardial wound. I I Such injurit·s that mi~ht affect various anatomic re~ions inchJ(lt· perforation of the heart which can lead to internal hlel>ding and death if surgical intervention is not institnted as soon as possihle.· When then' is an int raperkardial hemorrhage with sealed pericardial wound, cardiac tamponatll' is the major danger.' On the other hand, when the pt'ricardial wound is open and hll>eding (K't'IIrS freply into the pleural spacp, loss of circulating hlo(KI volnme wonld lit' the main threat.' We pn'sent a case with Iwrforation of hoth the pericardium and the lateral wall of thl' L\: in which the same I\('mopt>ricardium fornwd a dot that was capahle of sealing inside the pl'ricarclinlll creating a cavity within itself. and ht'cansl' it <.~)mmunicated to the L\: thl' patient did not develop a tamponadt·. More()\'I'r, this falst' aJwurysm, which filled during systole and emptied iu c1iastolt·, maintained tilt' patit'nt in stahll' ('ondition, allowing hilll to perfimn his work as a farmer "Ir /illlr months nntil he startt'd to decomlwnsatt' hemodynamically.
1474
11, our knowledge, this case rt'presents a rare complication that should lit' mnsidert'd when evaluatin~ penetratin~ wounds of tht' heart. ACKNOWLED(:MENT: The authors wish to thank Mrs. Adela Badui fur her assistance in the preparation of the manuscript. REFEHENCES
2 :1
4 5
Symhas P. Arenslwr~ D. Traumatic heart diseases. In: Hurst \Vj. The heart. 7th I'd. New York: Mc Graw Hill, 1990:1375 Sw~ W Rea \V, Ecker R, et al. Penetralin~ wounds of the heart: an analysis of 459 cast's. J Thurat· Cardiovasc Sur~ 1978; 56:531 Ran~t·1 A. Radui E, Verdust1l C, ValdespinH A, Enciso R. Trallluatic mronary arteriovenous fistula t')mmllllicatin~ the left main t1lfflllary artery to pulmonary artery, associated with pulmonary valvular insufficiency and end(K'ardilis: case report. An~iolo,-'y 19911: 41:156 Parmlt'y L, Matlin~ly 1: Manion W. Pt'netratin~ wounds of the heart and aorta. Circulation 1951;; 17:953 Issat·s P. Sixty Iwnetratin~ wounds of the heart. Sur~ery 1959; 4.';:096
6 Symhax P. Harlaflis "', Waldo W Pent·tratin~ cardiac wounds: a t1lmparison of difft'rt'nt therapt'ulic methods. Ann Sur~ 1976; 11l.1::177
False Aneurysm ollelt Ventricle (Badu; el all
this contact was made by breathin~. Tht, second ar~ument for tilt' responsihility of inhaled anti~ens is the demonstration of numerons actinomycetes in the patient's lun~ biopsy specinwn. In CSA. etiolo~ic and prt'cipitatin~ factors art' not dett'rmined in most cases and only rare publications" sUAAest that vaccination or desensitization could ht' factors triAAerin~ the vasculitis. The disease occurs in asthmatic patit'nts and the anti~en responsihle for the respiratory disease conld he inhaled. In other vasculitides such as We~ener's ~rannlo matosis, the occnrrence in patients who had inhaled wood particles advocalt-'s the responsihility of an inhaled anti~en. We snAAt'st, tllt'rt'fore, that inhaled anti~ens should be considered as possihle etiolo~ic factors fill' systemic vasculitis with respiratory manifestations. REFEHENt :ES
I Phannphak I~ Kohcl'r PF. Onst'l of polyarlt'ritis nCKlosa durin~ all....~k- hyposensiti/.ation trt'atml'n\. Am J I\It·d I~: 61i:47H-Ii.'5 2 Guillt'\'in L, Gnillard Til, Bldry 0, Godean P. Rosenthal P. Systemic Ilt'crolizin~ an~iitis with asthma: causI's and predpitatin~ factors in 43 caSt·s. Llln~ IHR7: Hi.'5: Hi.'5-72
False Aneurysm of the Left Ventricle due to a Penetrating Chest Wound* 1':lills 8(/(/ui, M.D., FC'.C.P.; Ros,,/IJt1 M"drid, M.D.; N'nlll/u/o Ayll/II, M.D.; Ho/It'rlo Enciso, M.D.; "1lI/
H"u/ \In/in, M.D.
A 24-year-old white man had a knife chest wound, and four months after this event, manifested progressive dyspnea. A false aneurysm of the left ventricle was diagnosed by 2D echocardiogram. Surgical resection of the aneurysmal sac with closure of the orifice of the lateral wall of the left ventricle was performed successfully. (Chest 1991; 100:1473-74) 4.mon~ tht· heart injuries due to pt'netratin~ chest traumas ~ are those secondary to perforation of tht' pericardinm
*From the Department of Cardiolo!.'Y, Ilospital dt· Especialidades. Centro l\Iedit'l la Raz'l, Institllto l\Iexk-ano d..l Se~uro Social. Mexiw City, Mexit". /U'Jlrinl rr'quI'slS: Dr. 8(/(/ui. 8usqUi' 1/" Gnlll"do.s .521, 8osl/w'.s 1/"
las V.mws, Mexico DF 11700, Mexico
F((;lIKE I. Chest x-ray film in which the cardiothoraci(' ratio (0.60) is increased due to the 11lIIkiness of the perit-ardial sac on the lateral wall of the left ventricle.
aud myocardium in a variety of manners. They include intt'rnal bleedin~ and hemopericardium with or without the development of tamponade. 1.2 In this report. we describe an unusual delayed complication of a penetratin~ wound of the heart manifested as a false aneurysm of the left ventricle. CASE REPOHT
A 24-year-old white male farmer, withont any important past nlt'dit'al history, durin~ a fi~ht received a knife stah wound on the lalt'ral wall of till' left hemithorax in the sixth left interwstal space at Ihe middle 'Lxilar line. The patient received first aid in a primary len'l clink- where a chest tnhe for pneumothorax was installed. After that, the patient apparently rewvered and refused further m'U1a~emen\. IIowever, four months later. he started complain in/.( of pro/.(ressive shortness of hreath for which he was referred to a third level hospital for further work-up. On physk-al examination, the patient was (,mscious and hemodynamically stahle. The hlood pressure was llOno mm II~: re~ular pulse at 100 per minute: respirations, 26 per minute with no fever. Ears. 1I0se, aud throat were normal. Carotid pulses were re~ular hilaterally. No jll/.(ular distention was present. Pulmonary lun~ fields ",('n' clear. Pulse of maximal intensity was localized at the fifth to sixth left interwstal space at the middle davicular line with paradoxic apical impulse. A soft <:ontinuous murmur /.(mde 214 was I"'ard al the ftlllrth left intermstal space at the middle davit'ular lillc. The rest of the physical examinalinn was unremarkahle. Lahoratory results. which included CBC, SMA 12. serum 1'11I.ymes. and eledmlytes as well as urinalysis, were within nnrmal limits. Reslin/.( electrocardio/.(ram shnwed sinus tachycardia, 100 per minute, with suhepicardial ischemia nn the lateral wall nf the left ventricle (LV). Cardiac x-ray series presented an incre'L~ed trallsversal heart diameter at the expense ..f the lateral wall nf the LV Wi/.( I). The M-mode e<:h..cardio/.(ram with Doppler detected a false aneurysm ..f the left ventricle, inside of which several small thmmhi were ohserved, as shown in Fi/.(ure 2. The patient was ..perated on. The false aneurysm ft>rmed by the Silme pericardial sac was resected and the ..rifice of the lateral wall of the LV was d ..sed. He recovered completely without any further mmplications. CHEST I 100 I 5 I NOVEMBER. 1991
1473
FICllRt: 2. A. A four-chamber view 2D echocarwith Doppler showin~ the false aneurysm Hf the left ventricle as is indicated by the arn>w. B. A close-up view Hf the perforated left ventricular wall, thrnu~ which a hidirectional Row was allowed within the LV and the FA durin~ the cardiac cycle. In systole, the FA was filled up, while in diastole. the hlooo Row returned to LV. In addition, the inner wall of the FA wa.s mvered with multiple small thrombi (T). RA is ri~ht atrium; RV. ri~ht ventricle; LA. left atrium. I,V. left ventricle; FA, false aneurysm; • and VAl, mitral valve. dio~ram
J)ISCliSSION Ht'art injuries sl>c(mdary to a penetrating chest trauma are divI'rsl' depeuding upon tht· modI', sight, and size of the lesion, and particularly, the state of the pericardial wound. I I Such injurit·s that mi~ht affect various anatomic re~ions inchJ(lt· perforation of the heart which can lead to internal hlel>ding and death if surgical intervention is not institnted as soon as possihle.· When then' is an int raperkardial hemorrhage with sealed pericardial wound, cardiac tamponatll' is the major danger.' On the other hand, when the pt'ricardial wound is open and hll>eding (K't'IIrS freply into the pleural spacp, loss of circulating hlo(KI volnme wonld lit' the main threat.' We pn'sent a case with Iwrforation of hoth the pericardium and the lateral wall of thl' L\: in which the same I\('mopt>ricardium fornwd a dot that was capahle of sealing inside the pl'ricarclinlll creating a cavity within itself. and ht'cansl' it <.~)mmunicated to the L\: thl' patient did not develop a tamponadt·. More()\'I'r, this falst' aJwurysm, which filled during systole and emptied iu c1iastolt·, maintained tilt' patit'nt in stahll' ('ondition, allowing hilll to perfimn his work as a farmer "Ir /illlr months nntil he startt'd to decomlwnsatt' hemodynamically.
1474
11, our knowledge, this case rt'presents a rare complication that should lit' mnsidert'd when evaluatin~ penetratin~ wounds of tht' heart. ACKNOWLED(:MENT: The authors wish to thank Mrs. Adela Badui fur her assistance in the preparation of the manuscript. REFEHENCES
2 :1
4 5
Symhas P. Arenslwr~ D. Traumatic heart diseases. In: Hurst \Vj. The heart. 7th I'd. New York: Mc Graw Hill, 1990:1375 Sw~ W Rea \V, Ecker R, et al. Penetralin~ wounds of the heart: an analysis of 459 cast's. J Thurat· Cardiovasc Sur~ 1978; 56:531 Ran~t·1 A. Radui E, Verdust1l C, ValdespinH A, Enciso R. Trallluatic mronary arteriovenous fistula t')mmllllicatin~ the left main t1lfflllary artery to pulmonary artery, associated with pulmonary valvular insufficiency and end(K'ardilis: case report. An~iolo,-'y 19911: 41:156 Parmlt'y L, Matlin~ly 1: Manion W. Pt'netratin~ wounds of the heart and aorta. Circulation 1951;; 17:953 Issat·s P. Sixty Iwnetratin~ wounds of the heart. Sur~ery 1959; 4.';:096
6 Symhax P. Harlaflis "', Waldo W Pent·tratin~ cardiac wounds: a t1lmparison of difft'rt'nt therapt'ulic methods. Ann Sur~ 1976; 11l.1::177
False Aneurysm ollelt Ventricle (Badu; el all