IMAGING IN CARDIOLOGY
Aorta-right ventricular fistula detected a few
days after thoracotomy for penetrating chest
trauma T.W. Galema, M.L. Geleijnse, J.A. Bekkers, F.J. ten Cate
Figure 1. Transthoracic echocardiograpby with colourDopplerflow throughfistula between ascending aorta and right ventricle.
A 23-year-old previously healthy man was transferred to our hospital because of a penetrating chest trauma. On admission the patient was in haemodynamic shock with a stab wound at the third intercostal space, a few centimetres left of his sternum. Transthoracic echocardiography (TIE) revealed pericardial fluid with right ventricular collapse. Pericardiocentesis was immediately performed and 150 ml T.W. Galema M.L GeleiJnse F.J. ten Cate Department of Cardiology, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands J.A. Bekkers Department of Cardiothoracic Surgery, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands
Correspondence to: T.W. Galema Department of Cardiology, Thoraxcentre, Room Ba 302, Erasmus Medical Centre, PO Box 2040, 3000 CA Rotterdam, the Netherlands E-mail: [email protected]
150
Figure 2. Pulsed Doppler signal of mitral inflow showing decrease of an E wave during inspiration indicating haemodynamic significance ofpericardialfluid.
sanguineous fluid was evacuated. Because of the suspicion of right ventricular free wall injury the patient was transported to the operating room. A median sternotomy was performed and after opening the pericardium a large amount of blood was removed. A transverse tear, 2 cm in length, was seen in the right ventricular outflow tract and repaired by a polypropylene suture. A mediastinal bleeding was caused by a total transsection of the left internal mammary artery. Both sides of the artery were oversewn. After three days the patient was discharged in good condition. Two days later the patient noticed a palpable thrill on the left side of his chest. TTE showed a fistula between the right ventricular outflow tract and the right sinus ofValsalva ofthe ascending aorta (figure 1). Additionally, a large amount of pericardial fluid was detected with a significant drop in passive mitral inflow during inspiration (figure 2). A reoperation was performed. Transoesophageal echocardiography (TOE) performed in the operating room showed the fistula from the right ventricle to the right sinus ofValsalva Netherlands Heart Journal, Volume 14, Number 4, April 2006
IMAGING IN CARDIOLOGY
RI---MI-.
during or shortly after the operation and this could be one ofthe reasons for missing intracardiac involvement. Using TTE performed a few days after the initial operation, Skoularigis et al. found intracardiac injury in nine of43 (2 1%) cases and performed TOE. In four ofthese nine patients (44%), TTE underestimated the extent ofthe injury.2 In patients with cardiac injury, TOE should be performed as soon as possible in the operation room or before discharge to avoid missing intracardiac injuries that need reoperation. v References 1
Figure 3. Transoesophageal echocardiography showingfistula next to ostium of right coronary artery.
2
3
close to the ostium of the right coronary artery (figure 3). The penicardial flu.id was evacuated and both sides of the fistula were closed through the ascending aorta and the pulmonary trunk with the patient on cardiopulmonary bypass. Five days later the patient was discharged in a good physical condition. Intracardiac lesions resulting from penetrating chest
trauma are relatively rare, with an incidence reported at 3 to 5%.' When two-dimensional echocardiographic imaging and colour-flow Doppler are routinely used, the incidence probably increases to 20%.2 In a literature review by Samuels et al. only 11 of 40 (28%) patients
with the final diagnosis of aorta-right ventricular fistula after penetrating chest trauma had their diagnosis established during the operation or on admission.3 Not all patients were routinely examined by TTE or TOE
|QC
Netherlands Heart Journal, Volume 14, Number 4, April 2006
Carter RL, Albert HM, Glass BA. Traumatic ventricular septal defect. Ann Thorac Surg 1967;4:256-9. Skoularigis J, Essop MR, Sarei P. Usefulness of transesophageal echocardiography in the early diagnosis of penetrating stab wounds to the heart. Am J Cardiol 1994:73:407-9. Samuels LE, Kaufman MS, Rodriguez-Vega J, Morris RJ, Brockman SK Diagnosis and management of traumatic aorto-right ventricular fistulas. Ann Thorac Surg 1998;65:288-92.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one page at the most) to Bohn Stafleu van Loghum, PO Box 246, 3990 GA Houten, e-mail: [email protected]. 'Moving images' are also welcomed and (after acceptance) will be published as aWeb Site Feature and shown on our website: www.cardiologie.nl
This section is edited by M.J.M. Cramer andjj. Bax.
151
Aorta-right ventricular fistula detected a few
days after thoracotomy for penetrating chest
trauma T.W. Galema, M.L. Geleijnse, J.A. Bekkers, F.J. ten Cate
Figure 1. Transthoracic echocardiograpby with colourDopplerflow throughfistula between ascending aorta and right ventricle.
A 23-year-old previously healthy man was transferred to our hospital because of a penetrating chest trauma. On admission the patient was in haemodynamic shock with a stab wound at the third intercostal space, a few centimetres left of his sternum. Transthoracic echocardiography (TIE) revealed pericardial fluid with right ventricular collapse. Pericardiocentesis was immediately performed and 150 ml T.W. Galema M.L GeleiJnse F.J. ten Cate Department of Cardiology, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands J.A. Bekkers Department of Cardiothoracic Surgery, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands
Correspondence to: T.W. Galema Department of Cardiology, Thoraxcentre, Room Ba 302, Erasmus Medical Centre, PO Box 2040, 3000 CA Rotterdam, the Netherlands E-mail: [email protected]
150
Figure 2. Pulsed Doppler signal of mitral inflow showing decrease of an E wave during inspiration indicating haemodynamic significance ofpericardialfluid.
sanguineous fluid was evacuated. Because of the suspicion of right ventricular free wall injury the patient was transported to the operating room. A median sternotomy was performed and after opening the pericardium a large amount of blood was removed. A transverse tear, 2 cm in length, was seen in the right ventricular outflow tract and repaired by a polypropylene suture. A mediastinal bleeding was caused by a total transsection of the left internal mammary artery. Both sides of the artery were oversewn. After three days the patient was discharged in good condition. Two days later the patient noticed a palpable thrill on the left side of his chest. TTE showed a fistula between the right ventricular outflow tract and the right sinus ofValsalva ofthe ascending aorta (figure 1). Additionally, a large amount of pericardial fluid was detected with a significant drop in passive mitral inflow during inspiration (figure 2). A reoperation was performed. Transoesophageal echocardiography (TOE) performed in the operating room showed the fistula from the right ventricle to the right sinus ofValsalva Netherlands Heart Journal, Volume 14, Number 4, April 2006
IMAGING IN CARDIOLOGY
RI---MI-.
during or shortly after the operation and this could be one ofthe reasons for missing intracardiac involvement. Using TTE performed a few days after the initial operation, Skoularigis et al. found intracardiac injury in nine of43 (2 1%) cases and performed TOE. In four ofthese nine patients (44%), TTE underestimated the extent ofthe injury.2 In patients with cardiac injury, TOE should be performed as soon as possible in the operation room or before discharge to avoid missing intracardiac injuries that need reoperation. v References 1
Figure 3. Transoesophageal echocardiography showingfistula next to ostium of right coronary artery.
2
3
close to the ostium of the right coronary artery (figure 3). The penicardial flu.id was evacuated and both sides of the fistula were closed through the ascending aorta and the pulmonary trunk with the patient on cardiopulmonary bypass. Five days later the patient was discharged in a good physical condition. Intracardiac lesions resulting from penetrating chest
trauma are relatively rare, with an incidence reported at 3 to 5%.' When two-dimensional echocardiographic imaging and colour-flow Doppler are routinely used, the incidence probably increases to 20%.2 In a literature review by Samuels et al. only 11 of 40 (28%) patients
with the final diagnosis of aorta-right ventricular fistula after penetrating chest trauma had their diagnosis established during the operation or on admission.3 Not all patients were routinely examined by TTE or TOE
|QC
Netherlands Heart Journal, Volume 14, Number 4, April 2006
Carter RL, Albert HM, Glass BA. Traumatic ventricular septal defect. Ann Thorac Surg 1967;4:256-9. Skoularigis J, Essop MR, Sarei P. Usefulness of transesophageal echocardiography in the early diagnosis of penetrating stab wounds to the heart. Am J Cardiol 1994:73:407-9. Samuels LE, Kaufman MS, Rodriguez-Vega J, Morris RJ, Brockman SK Diagnosis and management of traumatic aorto-right ventricular fistulas. Ann Thorac Surg 1998;65:288-92.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one page at the most) to Bohn Stafleu van Loghum, PO Box 246, 3990 GA Houten, e-mail: [email protected]. 'Moving images' are also welcomed and (after acceptance) will be published as aWeb Site Feature and shown on our website: www.cardiologie.nl
This section is edited by M.J.M. Cramer andjj. Bax.
151
