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Traumatic biventricular pseudoaneurysm of the heart with ventricular septal defect
Traumatic biventricular pseudoaneurysm of the heart with ventricular septal defect Panagiotis N. Symbas, M.D., R. Edwin Ware, M.D., Israel Belenkie, M.D., and Donald O. Nutter, M.D., Atlanta, Ga.
-L/eft ventricular aneurysms are frequently seen following acute myocardial infarction.110 Aneurysm of the heart or ventricular septal defects due to penetrating cardiac wounds are very rare. The purpose of this report is to record a case of biventricular aneurysm and ventricular septal defect due to a gunshot wound, an entity which, to the best of our knowledge, has never before been reported. Case report R. H. G., a 29-year-old woman, was admitted to a local hospital on July 31, 1971, with multiple 0.22 caliber gunshot wounds, one each to the chin, left arm, and left upper quadrant of the abdomen, and two to the anterior chest. One of the two thoracic bullets lodged in the chest wall and, as noted by serial roentgenograms, the other entered the thoracic esophagus and was eventually passed through the rectum. A left hemothorax was treated with a closed thoracotomy tube, and an emergency exploratory laparotomy was "negative." Her postoperative course was complicated by fever which did not not respond initially to high doses of penicillin. Several days after admission the discovery of a systolic murmur and an enlarging carFrom the Joseph B. Whitehead Department of Surgery, Thoracic and Cardiovascular Surgery Division, and the Department of Medicine, Emory University School of Medicine, Atlanta, Ga. Supported in part by U. S. Public Health Service Grants HE 05861, HE 5653, and HE 05731. Address for reprint requests: Dr. P. N. Symbas, 69 Butlei Street, S.E., Atlanta, Ga. 30303. Received for publication April 21, 1972.
diac silhouette on chest roentgenogram led to the suspicion of a traumatic intracardiac defect, and she was transferred to Grady Memorial Hospital on Aug. 13, 1971. On admission to our hospital, the patient was asymptomatic and appeared well. The blood pressure was 110/80 with 4 mm. Hg paradox, the pulse rate was 88 beats per minute and regular, respirations were unlabored at 20 breaths per minute, and the temperature was 99.6° F . The neck veins were not distended, and the apical impulse was not palpable. The first and second heart sounds were normal, and a Grade 2 of 6 continuous murmur was heard at the left sternal border in the second and third intercostal spaces. The chest roentgenogram revealed an enlarged cardiac silhouette, and the electrocardiogram yielded findings compatible with pericarditis. Following the spontaneous resolution of a moderate pericardial effusion, an abnormal systolic pulsation was noted just medial to the apical impulse in the third and fourth left intercostal spaces. At cardiac catheterization, a high interventricular left-to-right shunt was detected by hydrogen response times and was demonstrated angiographically. Also noted was an aneurysm of the lateral wall of the left ventricle, which appeared to empty into the right ventricular outflow tract via two fistulous tracts (Fig. 1 ) . On Oct. 5, 1971, the patient was operated upon. Through a median sternotomy incision, a 5 by 8 cm. intrapericardial bilobular pulsating mass was exposed on the anterolateral wall of the left ventricle and the outflow tract of the right ventricle (Fig. 2 ) . The aneurysm was opened under total cardiopulmonary bypass, and a well-formed thrombus partially filling the aneurysm was extracted. Two openings into the aneurysmal sac were found, one (5 mm.) communicating with the
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Fig. 1. Left cineventriculography demonstrates simultaneous opacification of the right ventricle, pulmonary artery (PA), aorta (Ao) and left ventricle (LV). A false aneurysm (a) appears to communicate via two fistulous tracts (F) with the outflow tract of the right ventricle. right ventricular outflow tract and the other (7 mm.) with the main chamber of the left ventricle; the two were joined by a small fistulous tract across the most anterior portion of the interventricular septum. Mature fibrous tissue circumscribing each wound afforded firm footing for suture material, and both myocardial wounds as well as the ventricular septal defect were easily approximated with simple sutures of 2.0 Tevdek. The patient's immediate postoperative course was not remarkable. At a 5 month follow-up, she is doing well with no problems referable to the cardiovascular system.
Discussion The majority (80 per cent) of cardiac aneurysms are due to myocardial infarction,3' "• ''■ whereas congenital9 or inflammatory10 aneurysms of the heart are extremely rare. Traumatic aneurysms, particularly those secondary to penetrating injury, are very rare. 8 ' 1X Perhaps this can be explained by the fact that only about 3 per cent of all penetrating chest injuries involve the heart12 and that 60 to 80 per cent of those patients with involvement of the heart die before they can be treated.12' 13 Although the right ventricle is the most frequently injured cardiac chamber from penetrating thoracic trauma, 1 almost all traumatic cardiac aneurysms involve the left ventricle. 1 ' 8 - 1X This may be explained by the low pressure of the right ventricular chamber, which facili-
Fig. 2. Photograph of the aneurysm (a) at the time of operation. LV, Left ventricle. RV, Right ventricle. PA, Pulmonary artery.
tates early and permanent sealing of these wounds.1 >3 In 1958, Lyons and Parkins reported the first successful surgical excision of a left ventricular aneurysm due to a stab wound. The same year, Parmley and associates12 recorded the first case of a left ventricular aneurysm and ventricular septal defect from a gunshot wound. The most recent report of traumatic cardiac aneurysm was that of Kakos and associates,11 who reviewed all 8 previously reported cases of left ventricular aneurysms secondary to penetrating trauma (except that of Parmley12 with an associated ventricular septal defect) and added their own case of a successfully repaired left ventricular aneurysm secondary to a bullet. Traumatic ventricular septal defect is also a rare entity. 1 ' 12 O'Neill,14 in 1951, was the first to repair successfully a traumatic interventricular communication resulting from a knife wound. Subsequently, several reports of septal defect secondary to both blunt and penetrating injury have appeared.1- 15' 1(i Concomitant ventricular septal defect and ventricular aneurysm caused by blunt trauma has been reported only twice in the literature,17' 18 and the association of these injuries secondary to penetrating trauma has been reported only once12 (Table I ) . So far as we can determine, a biventricular aneurysm associated with ventricular septal defect due to penetrating trauma has not been previously recorded.
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649
October, 1972
Table I. Traumatic ventricular
aneurysms
No. of
Author
(yr.j
cases reported and and reviewed* reviewed*
Treatment Type of Blunt
Aneurysms
Killen et al.8 (1969) Pupello et al.25 (1970) O'Reilly et al. 23 (1970) Kakosetal. 11 (1971) Totals Parmley et al.12 (1958) Green et al.18 (1965) Stinson et al.17 (1968) Present case (1971) Totals
19 (L) 1 (L) 1 (L) 3 (L)t 24 1 1 1 1 28
Penetrating
None
not associated with
13 1 1 15 (62.5%)
(L) (L) (R) (R md L)
trauma
6
Unknown
Survival
VSD
10
1
3 9 (37.5%)
Repair
10
1
8 1 1 3 13 (54.2%)
It ? 8 1 1 3 14 (58.3%)
Aneurysms associated with VSD 1 1 1
1 1 1
1 1 1
1
1
1
17 (60.7%) 11 (39.3%)
17 (60.7%) 18 (64.3%)
Legend: VSD, Ventricular septal defect. •Parentheses indicate left (L) or right (R) ventricle. tThree cases were added to the review by Killen's group, 2 reviewed from literature and 1 original case report. (The diagnosis was confirmed at thoracotomy, but the aneurysm was not excised due to proximity of the coronary artery.
Acquired cardiac aneurysms have been anatomically classified as true or false. True aneurysms,3 commonly caused by myocardial infarction1-10 and rarely by myocardial contusion,8- " • 1 8 are produced when the left ventricular pressure stretches the injured muscle. This thinned and dilated area eventually becomes densely fibrotic and may or may not have microscopically discernible muscle fibers.1'3-12 It is usually broad based, pulsates paradoxically with the left ventricle, and rarely ruptures. 2 The formation of a false aneurysm requires penetration of the myocardial wall, be it from within the cardiac chamber by blood under adequate pressure to create a defect in an area of injured muscle (infarction or contusion) or from without the myocardium by a missile or sharp instrument.1 '"• 1 2 All false aneurysms have a narrow orifice connecting them to the involved chamber and are formed by the clotted intrapericardial blood, which subsequently becomes cavitated by the turbulent flow from within the
cardiac chamber and encapsulated by a thick, fibrous wall. It is self evident that the path of a sharp instrument or missile is not only unpredictable but also has great bearing on the amount of injury sustained by the heart. In our patient, the course of the missile was assumed to have been tangential to the left anterolateral aspect of the heart, with shallow entrance into the most anterior portion of the left ventricle, passage across the interventricular septum near the anterior wall of the heart, an immediate exit through the anterior wall of the right ventricular outflow tract, and termination at the anterior chest wall. As a point of conjecture, one might postulate that the right ventricular wound and septal injury may have contributed to the patient's survival by providing shunt decompression of the intrapericardial blood emitted from the left ventricular wound. One of the most important factors in the diagnosis of any form of cardiac injury is a high index of suspicion in all cases of
650
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Thoracic and Cardiovascular Surgery
thoracic trauma. Following recovery from the initial traumatic event, some patients with traumatic aneurysm may be completely asymptomatic 1 - s ' " while others present with symptoms of congestive failure,3 dysrhythmia or embolic phenomena, 1,3> s chest pain, 3 - 8 ' "'•20 or sudden massive bleeding from rupture. 8 ' 19'21- -- Our patient had no symptoms referable to the cardiovascular system, and the possibility of cardiac injury was first entertained in her case with the discovery of a loud cardiac murmur. Murmurs occur very infrequently with the broad-based true aneurysm secondary to myocardial infarction4 but are not uncommon in traumatic aneurysms from blunt 18 - 23 or penetrating trauma. 24 They may be systolic, diastolic, or continuous as in the present case. An ectopic pulsation may be noted over the precordium due to the paradoxic motion of the aneurysm during ventricular systole. This finding was evident in our patient only after resorption of excessive post-traumatic pericardial fluid. Electrocardiographic changes may be present in cases of traumatic aneurysm,3 but very often the electrocardiogram is of limited diagnostic value. 8 ' 23 Routine chest roentgenography may reveal an abnormal cardiac silhouette. 8 ' 20 - 2i ' 25 On fluoroscopic examination, this usually appears as a left ventricular bulge in the true aneurysm or as a globular extension of the left ventricle in the false aneurysm. Paradoxic motion of the aneurysm is usually present in either case but may be prevented by calcification or intramural clotting.1 The specific diagnosis is confirmed only by angiocardiography with contrast material injected directly into the suspected chamber.20 This special diagnostic procedure also provides valuable preoperative information concerning over-all size, orifice size, relative position, mobility of the aneurysm, and the presence of clot. As with aneurysms secondary to coronary artery disease,2' 3 those due to trauma may be complicated by rupture, fatal arrhythmias, embolization, and cardiac failure. 2 ' 7 ' 8 These complications and the excellent prog-
nosis following the repair of the aneurysm suggest that traumatic ventricular aneurysms should be excised. The first repair for this type of aneurysm was performed without benefit of cardiopulmonary bypass.7 However, the advantages of using cardiopulmonary bypass, including direct visualization of the orifice, prevention of systemic embolization, protection from injury of the sometimes closely situated papillary muscles, and closure of a concomitant ventricular septal defect through the opening of the aneurysm18 indicate that this is the most satisfactory method of handling traumatic ventricular aneurysms in an unhurried fashion.1' 19 Aneurysm resulting from a stab wound should be repaired when the diagnosis is made, whereas those due to missile or blunt injury, because of the myocardial damage near the edge of the wound, should be repaired at a later date if possible. It is estimated that the formation of tough, fibrous tissue demarcating the edges of the wound and providing secure footing for suture material requires approximately 60 to 90 days. 3 ' 25 The fact that the traumatic aneurysms which have ruptured did so as early as 20 days after the injury (with an average of 49 days) 8 ' 19 ' 21 dictates that this waiting period be conducted with the patient under close observation by well-informed personnel in an area as close as possible to operating facilities.19'21 The operative mortality rate for all types of cardiac aneurysms has been estimated at 10 per cent.3 The surgical correction of traumatic aneurysms, which are usually associated with nondiseased coronary arteries, affords a much better immediate and certainly longterm prognosis, with no deaths attributed to operation in the 16 cases of surgical excision reported in the literature8' "• 12> 17' is, 23,25 a n c j m t n e p r e s e n t case (Table I ) . Summary Although cardiac aneurysms are not uncommon, it is unusual for them to develop as a result of trauma. The combination of traumatic ventricular aneurysm and ventricular septal defect has been reported only
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three times in the past. The rarity of these lesions may be explained by the infrequent involvement of the heart in chest injuries and by the high initial mortality rate of penetrating cardiac injuries, especially those from bullet wounds. We have described an unusual case of survival of a patient with multiple gunshot wounds, including wounds of both ventricular walls and the interventricular septum which resulted in a biventricular aneurysm and ventricular septal defect, all of which were successfully repaired. The incidence, anatomy, pathophysiology, clinical, diagnostic, and surgical aspects of traumatic cardiac aneurysm are briefly discussed. REFERENCES 1 Symbas, P. N.: Traumatic Injuries of the Heart and Great Vessels, Springfield, 1972, Charles C Thomas, Publisher, pp. 112-115. 2 Schlichter, J., Hellerstein, H. K., and Katz, C. N.: Aneurysm of the Heart: A Correlative Study of 102 Proved Cases, Medicine 33: 43, 1954. 3 Harley, H. R. S.: Cardiac Ventricular Aneurysm, Thorax 24: 148, 1969. 4 Gensini, G. G., and Martinez-Rios, M. A.: Aneurysm of Left Ventricle, N. Y. J. Med. 70: 1042, 1970. 5 Crawford, J. H.: Aneurysm of the Heart, Arch. Intern. Med. (Chicago) 71: 502, 1943. 6 Sternberg, M.: Das Chronische Pantielle Herz Aneurysma, Liepzig, Franz Deuticke, 1914 (cited by Crawford5). 7 Lyons, C , and Parkins, R.: Resection of a Left Ventricular Aneurysm Secondary to Cardiac Stab Wound, Ann. Surg. 147: 256, 1958. 8 Killen, D. A., Gobbel, W. G., France, R., and Vix, V. A.: Post-traumatic Aneurysm of the Left Ventricle, Circulation 39: 101, 1969. 9 Macleod, C. A., Ankeney, J. L., Perrin, E. V., Nickel, S. S., and Liebman, I.: Left Atrial Aneurysm, Am. Heart J. 80: 683, 1970. 10 Beckerling, C. H.: Left Ventricular Aneurysm, Thorax 24: 173, 1969. 11 Kakos, G. S., Williams, T. E., Kilman, J. W., and Klossen, K. P.: Traumatic Left Ventricular Aneurysms After Penetrating Chest Injury, Ann. Surg. 174: 202, 1971. 12 Parmley, L., Mattingly, T., and Manion, W. C :
Penetrating Wounds of the Heart, Circulation 17: 953, 1958. 13 Sugg, W. L., Rea, W. J., Ecker, R. R., Webb, W. R., Rose, E. F., and Shaw, R. R.: Penetrating Wounds of the Heart: An Analysis of 459 Cases, J. THORAC. CARDIOVASC. SURG. 56:
531, 1968. 14 O'Neill, T. I. E., cited by Peirce, E. C , II, Dabbs, H., and Rawson, F. L.: Isolated Rupture of the Ventricular Septum Due to Nonpenetrating Trauma: Report of a Case Treated by Open Cardiotomy Under Simple Hypothermia, Arch. Surg. (Chicago) 77: 87, 1958. 15 Summerell, C. P., Ill, Lee, W. H., Jr., and Boone, J. A.: Intracardiac Shunts After Penetrating Wounds of the Heart, N. Engl. J. Med. 272: 240, 1965. 16 Rogers, M. A., Chesner, E., and DuPlessis, L.: Surgical Management of Traumatic Cardiac Fistulae, Thorax 24: 543, 1969. 17 Stinson, E. B., Rowles, D. F., and Shumway, N. E.: Repair of Right Ventricular Aneurysm and Ventricular Septal Defect Causes by Nonpenetrating Trauma, Surgery 64: 1022, 1968. 18 Green, L., Oakley, C. M., Davies, D. M., and Cleland, W. P.: Successful Repair of Left Ventricular Aneurysm and Ventricular Septal Defect After Indirect Injury, Lancet 2: 984, 1965. 19 Aronstam, E. M., Lorenzo, D. S., Geiger, J. P., and Gomez, A. C : Traumatic Left Ventricular Aneurysms, J. THORAC. CARDIOVASC SURG. 59:
239, 1970. 20 Vix, V. A., and Killen, D. A.: Traumatic Pseudoaneurysm of the Left Ventricle, Am. J. Roentgenol. Radium Ther. Nucl. Med. 104: 413, 1968. 21 Panday, S. R., Parkar, G. B., Kelkar, M. D., and Sen, P. K.: Recurrent Hemorrhage From Iatrogenic Left Ventricular Aneurysm, Thorax 20: 510, 1965. 22 Pitts, H. H., and Purvis, G. S.: Ruptured Traumatic Cardiac Aneurysm in a Child, Can. Med. Assoc. J. 57: 165, 1947. 23 O'Reilly, R. J., Kazenelson, G., and Spellberg, R. D.: Traumatic Pseudoaneurysm of the Left Ventricle, Am. J. Dis. Child 120: 252, 1970. 24 Martinez-Lopez, J. I.: Pulsatory and Auscultory Phenomena in Pseudoaneurysm of the Heart, Am. J. Cardiol. 15: 422, 1965. 25 Pupello, D. F., Daily, P. O., Stinson, E. B., and Shumway, N. E.: Successful Repair of Left Ventricular Aneurysm Due to Trauma, J. A. M. A. 211: 826, 1970.
-L/eft ventricular aneurysms are frequently seen following acute myocardial infarction.110 Aneurysm of the heart or ventricular septal defects due to penetrating cardiac wounds are very rare. The purpose of this report is to record a case of biventricular aneurysm and ventricular septal defect due to a gunshot wound, an entity which, to the best of our knowledge, has never before been reported. Case report R. H. G., a 29-year-old woman, was admitted to a local hospital on July 31, 1971, with multiple 0.22 caliber gunshot wounds, one each to the chin, left arm, and left upper quadrant of the abdomen, and two to the anterior chest. One of the two thoracic bullets lodged in the chest wall and, as noted by serial roentgenograms, the other entered the thoracic esophagus and was eventually passed through the rectum. A left hemothorax was treated with a closed thoracotomy tube, and an emergency exploratory laparotomy was "negative." Her postoperative course was complicated by fever which did not not respond initially to high doses of penicillin. Several days after admission the discovery of a systolic murmur and an enlarging carFrom the Joseph B. Whitehead Department of Surgery, Thoracic and Cardiovascular Surgery Division, and the Department of Medicine, Emory University School of Medicine, Atlanta, Ga. Supported in part by U. S. Public Health Service Grants HE 05861, HE 5653, and HE 05731. Address for reprint requests: Dr. P. N. Symbas, 69 Butlei Street, S.E., Atlanta, Ga. 30303. Received for publication April 21, 1972.
diac silhouette on chest roentgenogram led to the suspicion of a traumatic intracardiac defect, and she was transferred to Grady Memorial Hospital on Aug. 13, 1971. On admission to our hospital, the patient was asymptomatic and appeared well. The blood pressure was 110/80 with 4 mm. Hg paradox, the pulse rate was 88 beats per minute and regular, respirations were unlabored at 20 breaths per minute, and the temperature was 99.6° F . The neck veins were not distended, and the apical impulse was not palpable. The first and second heart sounds were normal, and a Grade 2 of 6 continuous murmur was heard at the left sternal border in the second and third intercostal spaces. The chest roentgenogram revealed an enlarged cardiac silhouette, and the electrocardiogram yielded findings compatible with pericarditis. Following the spontaneous resolution of a moderate pericardial effusion, an abnormal systolic pulsation was noted just medial to the apical impulse in the third and fourth left intercostal spaces. At cardiac catheterization, a high interventricular left-to-right shunt was detected by hydrogen response times and was demonstrated angiographically. Also noted was an aneurysm of the lateral wall of the left ventricle, which appeared to empty into the right ventricular outflow tract via two fistulous tracts (Fig. 1 ) . On Oct. 5, 1971, the patient was operated upon. Through a median sternotomy incision, a 5 by 8 cm. intrapericardial bilobular pulsating mass was exposed on the anterolateral wall of the left ventricle and the outflow tract of the right ventricle (Fig. 2 ) . The aneurysm was opened under total cardiopulmonary bypass, and a well-formed thrombus partially filling the aneurysm was extracted. Two openings into the aneurysmal sac were found, one (5 mm.) communicating with the
647
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The Journal of
Symbas et al.
Thoracic and Cardiovascular Surgery
Fig. 1. Left cineventriculography demonstrates simultaneous opacification of the right ventricle, pulmonary artery (PA), aorta (Ao) and left ventricle (LV). A false aneurysm (a) appears to communicate via two fistulous tracts (F) with the outflow tract of the right ventricle. right ventricular outflow tract and the other (7 mm.) with the main chamber of the left ventricle; the two were joined by a small fistulous tract across the most anterior portion of the interventricular septum. Mature fibrous tissue circumscribing each wound afforded firm footing for suture material, and both myocardial wounds as well as the ventricular septal defect were easily approximated with simple sutures of 2.0 Tevdek. The patient's immediate postoperative course was not remarkable. At a 5 month follow-up, she is doing well with no problems referable to the cardiovascular system.
Discussion The majority (80 per cent) of cardiac aneurysms are due to myocardial infarction,3' "• ''■ whereas congenital9 or inflammatory10 aneurysms of the heart are extremely rare. Traumatic aneurysms, particularly those secondary to penetrating injury, are very rare. 8 ' 1X Perhaps this can be explained by the fact that only about 3 per cent of all penetrating chest injuries involve the heart12 and that 60 to 80 per cent of those patients with involvement of the heart die before they can be treated.12' 13 Although the right ventricle is the most frequently injured cardiac chamber from penetrating thoracic trauma, 1 almost all traumatic cardiac aneurysms involve the left ventricle. 1 ' 8 - 1X This may be explained by the low pressure of the right ventricular chamber, which facili-
Fig. 2. Photograph of the aneurysm (a) at the time of operation. LV, Left ventricle. RV, Right ventricle. PA, Pulmonary artery.
tates early and permanent sealing of these wounds.1 >3 In 1958, Lyons and Parkins reported the first successful surgical excision of a left ventricular aneurysm due to a stab wound. The same year, Parmley and associates12 recorded the first case of a left ventricular aneurysm and ventricular septal defect from a gunshot wound. The most recent report of traumatic cardiac aneurysm was that of Kakos and associates,11 who reviewed all 8 previously reported cases of left ventricular aneurysms secondary to penetrating trauma (except that of Parmley12 with an associated ventricular septal defect) and added their own case of a successfully repaired left ventricular aneurysm secondary to a bullet. Traumatic ventricular septal defect is also a rare entity. 1 ' 12 O'Neill,14 in 1951, was the first to repair successfully a traumatic interventricular communication resulting from a knife wound. Subsequently, several reports of septal defect secondary to both blunt and penetrating injury have appeared.1- 15' 1(i Concomitant ventricular septal defect and ventricular aneurysm caused by blunt trauma has been reported only twice in the literature,17' 18 and the association of these injuries secondary to penetrating trauma has been reported only once12 (Table I ) . So far as we can determine, a biventricular aneurysm associated with ventricular septal defect due to penetrating trauma has not been previously recorded.
Volume 64
Number 4
Traumatic pseudoaneurysm with VSD
649
October, 1972
Table I. Traumatic ventricular
aneurysms
No. of
Author
(yr.j
cases reported and and reviewed* reviewed*
Treatment Type of Blunt
Aneurysms
Killen et al.8 (1969) Pupello et al.25 (1970) O'Reilly et al. 23 (1970) Kakosetal. 11 (1971) Totals Parmley et al.12 (1958) Green et al.18 (1965) Stinson et al.17 (1968) Present case (1971) Totals
19 (L) 1 (L) 1 (L) 3 (L)t 24 1 1 1 1 28
Penetrating
None
not associated with
13 1 1 15 (62.5%)
(L) (L) (R) (R md L)
trauma
6
Unknown
Survival
VSD
10
1
3 9 (37.5%)
Repair
10
1
8 1 1 3 13 (54.2%)
It ? 8 1 1 3 14 (58.3%)
Aneurysms associated with VSD 1 1 1
1 1 1
1 1 1
1
1
1
17 (60.7%) 11 (39.3%)
17 (60.7%) 18 (64.3%)
Legend: VSD, Ventricular septal defect. •Parentheses indicate left (L) or right (R) ventricle. tThree cases were added to the review by Killen's group, 2 reviewed from literature and 1 original case report. (The diagnosis was confirmed at thoracotomy, but the aneurysm was not excised due to proximity of the coronary artery.
Acquired cardiac aneurysms have been anatomically classified as true or false. True aneurysms,3 commonly caused by myocardial infarction1-10 and rarely by myocardial contusion,8- " • 1 8 are produced when the left ventricular pressure stretches the injured muscle. This thinned and dilated area eventually becomes densely fibrotic and may or may not have microscopically discernible muscle fibers.1'3-12 It is usually broad based, pulsates paradoxically with the left ventricle, and rarely ruptures. 2 The formation of a false aneurysm requires penetration of the myocardial wall, be it from within the cardiac chamber by blood under adequate pressure to create a defect in an area of injured muscle (infarction or contusion) or from without the myocardium by a missile or sharp instrument.1 '"• 1 2 All false aneurysms have a narrow orifice connecting them to the involved chamber and are formed by the clotted intrapericardial blood, which subsequently becomes cavitated by the turbulent flow from within the
cardiac chamber and encapsulated by a thick, fibrous wall. It is self evident that the path of a sharp instrument or missile is not only unpredictable but also has great bearing on the amount of injury sustained by the heart. In our patient, the course of the missile was assumed to have been tangential to the left anterolateral aspect of the heart, with shallow entrance into the most anterior portion of the left ventricle, passage across the interventricular septum near the anterior wall of the heart, an immediate exit through the anterior wall of the right ventricular outflow tract, and termination at the anterior chest wall. As a point of conjecture, one might postulate that the right ventricular wound and septal injury may have contributed to the patient's survival by providing shunt decompression of the intrapericardial blood emitted from the left ventricular wound. One of the most important factors in the diagnosis of any form of cardiac injury is a high index of suspicion in all cases of
650
The Journal of
Symbas et al.
Thoracic and Cardiovascular Surgery
thoracic trauma. Following recovery from the initial traumatic event, some patients with traumatic aneurysm may be completely asymptomatic 1 - s ' " while others present with symptoms of congestive failure,3 dysrhythmia or embolic phenomena, 1,3> s chest pain, 3 - 8 ' "'•20 or sudden massive bleeding from rupture. 8 ' 19'21- -- Our patient had no symptoms referable to the cardiovascular system, and the possibility of cardiac injury was first entertained in her case with the discovery of a loud cardiac murmur. Murmurs occur very infrequently with the broad-based true aneurysm secondary to myocardial infarction4 but are not uncommon in traumatic aneurysms from blunt 18 - 23 or penetrating trauma. 24 They may be systolic, diastolic, or continuous as in the present case. An ectopic pulsation may be noted over the precordium due to the paradoxic motion of the aneurysm during ventricular systole. This finding was evident in our patient only after resorption of excessive post-traumatic pericardial fluid. Electrocardiographic changes may be present in cases of traumatic aneurysm,3 but very often the electrocardiogram is of limited diagnostic value. 8 ' 23 Routine chest roentgenography may reveal an abnormal cardiac silhouette. 8 ' 20 - 2i ' 25 On fluoroscopic examination, this usually appears as a left ventricular bulge in the true aneurysm or as a globular extension of the left ventricle in the false aneurysm. Paradoxic motion of the aneurysm is usually present in either case but may be prevented by calcification or intramural clotting.1 The specific diagnosis is confirmed only by angiocardiography with contrast material injected directly into the suspected chamber.20 This special diagnostic procedure also provides valuable preoperative information concerning over-all size, orifice size, relative position, mobility of the aneurysm, and the presence of clot. As with aneurysms secondary to coronary artery disease,2' 3 those due to trauma may be complicated by rupture, fatal arrhythmias, embolization, and cardiac failure. 2 ' 7 ' 8 These complications and the excellent prog-
nosis following the repair of the aneurysm suggest that traumatic ventricular aneurysms should be excised. The first repair for this type of aneurysm was performed without benefit of cardiopulmonary bypass.7 However, the advantages of using cardiopulmonary bypass, including direct visualization of the orifice, prevention of systemic embolization, protection from injury of the sometimes closely situated papillary muscles, and closure of a concomitant ventricular septal defect through the opening of the aneurysm18 indicate that this is the most satisfactory method of handling traumatic ventricular aneurysms in an unhurried fashion.1' 19 Aneurysm resulting from a stab wound should be repaired when the diagnosis is made, whereas those due to missile or blunt injury, because of the myocardial damage near the edge of the wound, should be repaired at a later date if possible. It is estimated that the formation of tough, fibrous tissue demarcating the edges of the wound and providing secure footing for suture material requires approximately 60 to 90 days. 3 ' 25 The fact that the traumatic aneurysms which have ruptured did so as early as 20 days after the injury (with an average of 49 days) 8 ' 19 ' 21 dictates that this waiting period be conducted with the patient under close observation by well-informed personnel in an area as close as possible to operating facilities.19'21 The operative mortality rate for all types of cardiac aneurysms has been estimated at 10 per cent.3 The surgical correction of traumatic aneurysms, which are usually associated with nondiseased coronary arteries, affords a much better immediate and certainly longterm prognosis, with no deaths attributed to operation in the 16 cases of surgical excision reported in the literature8' "• 12> 17' is, 23,25 a n c j m t n e p r e s e n t case (Table I ) . Summary Although cardiac aneurysms are not uncommon, it is unusual for them to develop as a result of trauma. The combination of traumatic ventricular aneurysm and ventricular septal defect has been reported only
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with VSD
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three times in the past. The rarity of these lesions may be explained by the infrequent involvement of the heart in chest injuries and by the high initial mortality rate of penetrating cardiac injuries, especially those from bullet wounds. We have described an unusual case of survival of a patient with multiple gunshot wounds, including wounds of both ventricular walls and the interventricular septum which resulted in a biventricular aneurysm and ventricular septal defect, all of which were successfully repaired. The incidence, anatomy, pathophysiology, clinical, diagnostic, and surgical aspects of traumatic cardiac aneurysm are briefly discussed. REFERENCES 1 Symbas, P. N.: Traumatic Injuries of the Heart and Great Vessels, Springfield, 1972, Charles C Thomas, Publisher, pp. 112-115. 2 Schlichter, J., Hellerstein, H. K., and Katz, C. N.: Aneurysm of the Heart: A Correlative Study of 102 Proved Cases, Medicine 33: 43, 1954. 3 Harley, H. R. S.: Cardiac Ventricular Aneurysm, Thorax 24: 148, 1969. 4 Gensini, G. G., and Martinez-Rios, M. A.: Aneurysm of Left Ventricle, N. Y. J. Med. 70: 1042, 1970. 5 Crawford, J. H.: Aneurysm of the Heart, Arch. Intern. Med. (Chicago) 71: 502, 1943. 6 Sternberg, M.: Das Chronische Pantielle Herz Aneurysma, Liepzig, Franz Deuticke, 1914 (cited by Crawford5). 7 Lyons, C , and Parkins, R.: Resection of a Left Ventricular Aneurysm Secondary to Cardiac Stab Wound, Ann. Surg. 147: 256, 1958. 8 Killen, D. A., Gobbel, W. G., France, R., and Vix, V. A.: Post-traumatic Aneurysm of the Left Ventricle, Circulation 39: 101, 1969. 9 Macleod, C. A., Ankeney, J. L., Perrin, E. V., Nickel, S. S., and Liebman, I.: Left Atrial Aneurysm, Am. Heart J. 80: 683, 1970. 10 Beckerling, C. H.: Left Ventricular Aneurysm, Thorax 24: 173, 1969. 11 Kakos, G. S., Williams, T. E., Kilman, J. W., and Klossen, K. P.: Traumatic Left Ventricular Aneurysms After Penetrating Chest Injury, Ann. Surg. 174: 202, 1971. 12 Parmley, L., Mattingly, T., and Manion, W. C :
Penetrating Wounds of the Heart, Circulation 17: 953, 1958. 13 Sugg, W. L., Rea, W. J., Ecker, R. R., Webb, W. R., Rose, E. F., and Shaw, R. R.: Penetrating Wounds of the Heart: An Analysis of 459 Cases, J. THORAC. CARDIOVASC. SURG. 56:
531, 1968. 14 O'Neill, T. I. E., cited by Peirce, E. C , II, Dabbs, H., and Rawson, F. L.: Isolated Rupture of the Ventricular Septum Due to Nonpenetrating Trauma: Report of a Case Treated by Open Cardiotomy Under Simple Hypothermia, Arch. Surg. (Chicago) 77: 87, 1958. 15 Summerell, C. P., Ill, Lee, W. H., Jr., and Boone, J. A.: Intracardiac Shunts After Penetrating Wounds of the Heart, N. Engl. J. Med. 272: 240, 1965. 16 Rogers, M. A., Chesner, E., and DuPlessis, L.: Surgical Management of Traumatic Cardiac Fistulae, Thorax 24: 543, 1969. 17 Stinson, E. B., Rowles, D. F., and Shumway, N. E.: Repair of Right Ventricular Aneurysm and Ventricular Septal Defect Causes by Nonpenetrating Trauma, Surgery 64: 1022, 1968. 18 Green, L., Oakley, C. M., Davies, D. M., and Cleland, W. P.: Successful Repair of Left Ventricular Aneurysm and Ventricular Septal Defect After Indirect Injury, Lancet 2: 984, 1965. 19 Aronstam, E. M., Lorenzo, D. S., Geiger, J. P., and Gomez, A. C : Traumatic Left Ventricular Aneurysms, J. THORAC. CARDIOVASC SURG. 59:
239, 1970. 20 Vix, V. A., and Killen, D. A.: Traumatic Pseudoaneurysm of the Left Ventricle, Am. J. Roentgenol. Radium Ther. Nucl. Med. 104: 413, 1968. 21 Panday, S. R., Parkar, G. B., Kelkar, M. D., and Sen, P. K.: Recurrent Hemorrhage From Iatrogenic Left Ventricular Aneurysm, Thorax 20: 510, 1965. 22 Pitts, H. H., and Purvis, G. S.: Ruptured Traumatic Cardiac Aneurysm in a Child, Can. Med. Assoc. J. 57: 165, 1947. 23 O'Reilly, R. J., Kazenelson, G., and Spellberg, R. D.: Traumatic Pseudoaneurysm of the Left Ventricle, Am. J. Dis. Child 120: 252, 1970. 24 Martinez-Lopez, J. I.: Pulsatory and Auscultory Phenomena in Pseudoaneurysm of the Heart, Am. J. Cardiol. 15: 422, 1965. 25 Pupello, D. F., Daily, P. O., Stinson, E. B., and Shumway, N. E.: Successful Repair of Left Ventricular Aneurysm Due to Trauma, J. A. M. A. 211: 826, 1970.