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Isolated rupture of the interventricular septum due to a fall from a height
International Journal of Cardiology 98 (2005) 525 – 526 www.elsevier.com/locate/ijcard
Letter to the Editor
Isolated rupture of the interventricular septum due to a fall from a height R. Lee *, D.S. Gill, Q.W. Yong Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore Received 24 July 2003; accepted 3 November 2003 Available online 18 May 2004
Isolated ventricular septal defect (VSD) is a very rare complication of blunt chest trauma. Cardiac injuries following blunt chest trauma usually result from motor vehicle accidents. We present the unusual case of an isolated rupture of the interventricular septum after a fall from a height. A previously healthy 25-year-old construction worker was admitted to hospital after a fall from a height of 10 m. Physical examination revealed no visible signs of chest wall injury. He was hemodynamically stable with a pulse rate of 130 bpm and BP of 115/65. Cardiac examination did not reveal any murmurs. He sustained fractures of the right femur, left clavicle and facial bones. There were no sternal or rib fractures. Eight hours later, a loud pansystolic murmur (4/6) was heard along the left sternal border. ECG showed ST elevation in the anteroseptal leads (Fig. 1). Troponin I was elevated at 6.9 Ag/l (normal < 0.33 Ag/l). Transthoracic echocardiogram revealed a 4 mm apical VSD (Fig. 2). Continuous wave Doppler demonstrated a left to right shunt with a peak velocity of 4.8 m/s. The calculated pulmonary to systemic flow ratio (Qp/Qs) was 1.4 to 1. Pulmonary artery systolic pressure was 44 mm Hg. Left ventricular systolic function was normal with an ejection fraction of 55%. Cardiac chambers were not dilated. A clinical diagnosis of traumatic VSD due to myocardial contusion was made. As the patient remained stable without evidence of heart failure, he was managed conservatively. He received infective endocarditis antibiotic prophylaxis during orthopaedic surgery. He made an uneventful recovery and was discharged with cardiology clinic follow up. Isolated VSD after blunt chest trauma is extremely rare. Parmley et al. [1] reviewed the autopsy findings of 5467 cases of blunt chest trauma and found only five cases of * Corresponding author. Tel.: +65-6357-7831; fax: +65-6352-6682. E-mail address: [email protected] (R. Lee). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.037
isolated VSD. To our knowledge, this is only the second reported case of an isolated VSD after a fall from a height [2]. Traumatic VSD may occur immediately or may be delayed for days or even months after injury. The clinical presentation varies depending on the severity of the contusion and the magnitude of the intracardiac shunt. Patients may be asymptomatic or may present with heart failure or cardiogenic shock. The pathogenesis is most likely related to compression of the heart between the sternum and the spine during late diastole and early systole when the ventricles are full. Athough any part of the septum may be involved, the apex is the most common site of rupture [3]. The diagnosis of traumatic VSD is suggested by the presence a new pansystolic murmur and elevated cardiac troponin. Echocardiography is essential to confirm the diagnosis, assess hemodynamics and exclude other lesions. Patients with small traumatic VSD’s (Qp/Qs < 2:1) could be managed conservatively with regular follow up and serial echocardiograms. Studies have shown that small traumatic VSD’s may remain hemodynamically stable for years or even spontaneously close over time [4,5]. Infective endocarditis antibiotic prophylaxis should be given to all patients. Large traumatic VSD’s (Qp/Qs>2: 1) should be surgically closed to prevent development of congestive cardiac failure and pulmonary hypertension. The timing of surgery depends on the patient’s hemodynamic status. If hemodynamically stable, surgery maybe delayed to give time for the heart to recover from the contusion and allow fibrosis to develop around the defect, permitting more secure suture placement [6]. The possibility of traumatic VSD should be considered in all multiple trauma patients who develop a new murmur even when overt chest wall injury is absent. Early diagnosis allows the optimal management of these patients.
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R. Lee et al. / International Journal of Cardiology 98 (2005) 525–526
Fig. 1. ECG showing ST elevation in the anteroseptal leads (V1 to V3) consistent with myocardial contusion.
Fig. 2. Apical 4 chamber view showing a traumatic apical VSD with left to right shunt on colour flow doppler; RA: right atrium; LA: left atrium; LV: left ventricle; VSD: ventricular septal defect.
References [1] Parmley LF, Manion WC, Mattingly TW. Non penetrating traumatic injury on the heart. Circulation 1958;18:371 – 96. [2] Chou TF, Hwang JJ, Chu SH. Interventricular septum rupture due to falling from a height. Thorac Cardiovasc Surg 1991 (Dec.);39(6): 379 – 81. [3] Evora PRB, Ribeiro PJF, Brasil JCF. Late surgical repair of ventricular septal defect due to nonpenetrating chest trauma: review and report of two contrasting cases. J Trauma 1985;25:1007 – 9.
[4] Perzada F, McDowell J, Cohen E. Traumatic ventricular septal defect: sequential hemodynamic observations. N Engl J Med 1974;291: 892 – 5. [5] Ilia R, Goldfarb B, Wanderman KL, Gueron M. Spontaneous closure of a traumatic ventricular septal defect after blunt trauma demonstrated by serial echocardiography. J Am Soc Echocardiogr 1992 (Mar. – Apr.); 5(2):203 – 5. [6] Cowgill LD, Campbell DN, Clarke DR, Hammermeister K, Groves BM, Woelfel GF. Ventricular septal defect due to non penetrating chest trauma: use of the intraaortic balloon pump. J Trauma 1987;27:1087 – 9.
Letter to the Editor
Isolated rupture of the interventricular septum due to a fall from a height R. Lee *, D.S. Gill, Q.W. Yong Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore Received 24 July 2003; accepted 3 November 2003 Available online 18 May 2004
Isolated ventricular septal defect (VSD) is a very rare complication of blunt chest trauma. Cardiac injuries following blunt chest trauma usually result from motor vehicle accidents. We present the unusual case of an isolated rupture of the interventricular septum after a fall from a height. A previously healthy 25-year-old construction worker was admitted to hospital after a fall from a height of 10 m. Physical examination revealed no visible signs of chest wall injury. He was hemodynamically stable with a pulse rate of 130 bpm and BP of 115/65. Cardiac examination did not reveal any murmurs. He sustained fractures of the right femur, left clavicle and facial bones. There were no sternal or rib fractures. Eight hours later, a loud pansystolic murmur (4/6) was heard along the left sternal border. ECG showed ST elevation in the anteroseptal leads (Fig. 1). Troponin I was elevated at 6.9 Ag/l (normal < 0.33 Ag/l). Transthoracic echocardiogram revealed a 4 mm apical VSD (Fig. 2). Continuous wave Doppler demonstrated a left to right shunt with a peak velocity of 4.8 m/s. The calculated pulmonary to systemic flow ratio (Qp/Qs) was 1.4 to 1. Pulmonary artery systolic pressure was 44 mm Hg. Left ventricular systolic function was normal with an ejection fraction of 55%. Cardiac chambers were not dilated. A clinical diagnosis of traumatic VSD due to myocardial contusion was made. As the patient remained stable without evidence of heart failure, he was managed conservatively. He received infective endocarditis antibiotic prophylaxis during orthopaedic surgery. He made an uneventful recovery and was discharged with cardiology clinic follow up. Isolated VSD after blunt chest trauma is extremely rare. Parmley et al. [1] reviewed the autopsy findings of 5467 cases of blunt chest trauma and found only five cases of * Corresponding author. Tel.: +65-6357-7831; fax: +65-6352-6682. E-mail address: [email protected] (R. Lee). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.037
isolated VSD. To our knowledge, this is only the second reported case of an isolated VSD after a fall from a height [2]. Traumatic VSD may occur immediately or may be delayed for days or even months after injury. The clinical presentation varies depending on the severity of the contusion and the magnitude of the intracardiac shunt. Patients may be asymptomatic or may present with heart failure or cardiogenic shock. The pathogenesis is most likely related to compression of the heart between the sternum and the spine during late diastole and early systole when the ventricles are full. Athough any part of the septum may be involved, the apex is the most common site of rupture [3]. The diagnosis of traumatic VSD is suggested by the presence a new pansystolic murmur and elevated cardiac troponin. Echocardiography is essential to confirm the diagnosis, assess hemodynamics and exclude other lesions. Patients with small traumatic VSD’s (Qp/Qs < 2:1) could be managed conservatively with regular follow up and serial echocardiograms. Studies have shown that small traumatic VSD’s may remain hemodynamically stable for years or even spontaneously close over time [4,5]. Infective endocarditis antibiotic prophylaxis should be given to all patients. Large traumatic VSD’s (Qp/Qs>2: 1) should be surgically closed to prevent development of congestive cardiac failure and pulmonary hypertension. The timing of surgery depends on the patient’s hemodynamic status. If hemodynamically stable, surgery maybe delayed to give time for the heart to recover from the contusion and allow fibrosis to develop around the defect, permitting more secure suture placement [6]. The possibility of traumatic VSD should be considered in all multiple trauma patients who develop a new murmur even when overt chest wall injury is absent. Early diagnosis allows the optimal management of these patients.
526
R. Lee et al. / International Journal of Cardiology 98 (2005) 525–526
Fig. 1. ECG showing ST elevation in the anteroseptal leads (V1 to V3) consistent with myocardial contusion.
Fig. 2. Apical 4 chamber view showing a traumatic apical VSD with left to right shunt on colour flow doppler; RA: right atrium; LA: left atrium; LV: left ventricle; VSD: ventricular septal defect.
References [1] Parmley LF, Manion WC, Mattingly TW. Non penetrating traumatic injury on the heart. Circulation 1958;18:371 – 96. [2] Chou TF, Hwang JJ, Chu SH. Interventricular septum rupture due to falling from a height. Thorac Cardiovasc Surg 1991 (Dec.);39(6): 379 – 81. [3] Evora PRB, Ribeiro PJF, Brasil JCF. Late surgical repair of ventricular septal defect due to nonpenetrating chest trauma: review and report of two contrasting cases. J Trauma 1985;25:1007 – 9.
[4] Perzada F, McDowell J, Cohen E. Traumatic ventricular septal defect: sequential hemodynamic observations. N Engl J Med 1974;291: 892 – 5. [5] Ilia R, Goldfarb B, Wanderman KL, Gueron M. Spontaneous closure of a traumatic ventricular septal defect after blunt trauma demonstrated by serial echocardiography. J Am Soc Echocardiogr 1992 (Mar. – Apr.); 5(2):203 – 5. [6] Cowgill LD, Campbell DN, Clarke DR, Hammermeister K, Groves BM, Woelfel GF. Ventricular septal defect due to non penetrating chest trauma: use of the intraaortic balloon pump. J Trauma 1987;27:1087 – 9.