Gen Thorac Cardiovasc Surg DOI 10.1007/s11748-014-0391-0
CASE REPORT
Traumatic pseudoaneurysm of the heart Ranjan Sapkota • Bhagawan Koirala
Received: 20 September 2013 / Accepted: 4 March 2014 Ó The Japanese Association for Thoracic Surgery 2014
Abstract Missile injuries to heart are one of the most severe penetrating chest injuries, and mostly fatal. The presentation in those who survive may be unusual and insidious. Pseudoaneurysms of the heart, usually sequel to myocardial infarction, may rarely present after penetrating cardiac wounds. Their management is a challenging one, and requires the provision of cardiopulmonary bypass. We report a case of ventricular pseudoaneurysm as a consequence of bullet injury, successfully managed in our center. Keywords
Heart Injury Pseudoaneurysm
Introduction It was in 1897 that Rehn first sutured a cardiac wound successfully [1]. Generally, a penetrating injury to the heart is considered potentially fatal. Patients with missile wounds of the heart are far less likely to survive than those with stab wounds [2]. Pseudoaneurysm of the heart is a rare condition that occurs when ventricular free wall rupture is contained by the surrounding adherent pericardium or scar tissue. Ventricular pseudoaneurysms usually occur after myocardial infarction, but can also be a sequel to cardiac surgery, trauma and infection [3]. Left ventricle is the most common site. Management of traumatic pseudoaneurysm of the heart is challenging and requires careful applications
R. Sapkota (&) B. Koirala Department of Cardio-Thoracic and Vascular Surgery, Manmohan Cardio-Thoracic Vascular and Transplant Center, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal e-mail: [email protected] B. Koirala e-mail: [email protected]
of principles of cardiac surgery. We report a similar case successfully managed at our center.
Case report A 32-year-old male was brought to the emergency room (ER) after 9 h of being shot from an intermediate range. He sustained injuries at his right lower jaw, chin and anterior chest. At presentation in ER, he was alert, hemodynamically stable and only complained of pain at the wound sites and upper abdomen. The 1 9 1 cm entry wound was on the right lower jaw, and there were two more wounds, both 1 9 1 cm, on the undersurface of the chin and left 3rd intercostal space just lateral to the midline (Fig. 1). Air entry was equal on both sides of the chest; heart sounds were normally heard, without any murmur, and neck veins were not engorged. Upper abdomen was slightly full and tender, with some guarding and rigidity. Chest X-ray showed the bullet below the left hemidiaphragm. The contrast-enhanced computed tomogram (CECT) of the chest showed the bullet impinging on the wall of the greater curvature of the stomach. Both the CECT and the Echocardiogram showed small pericardial effusion, without features of tamponade (Fig. 2). There was no subcutaneous emphysema or pneumothorax, both clinically as well as radiologically. Thus in the first evaluation the injury to esophagus and airway were reasonably ruled out. Cardiac injury was also thought to be absent in view of small, non-progressing effusion, and absence of any hemodynamic compromise or tamponade. But in view of subtly progressing peritonitis and with the bullet in the abdomen, a quick laparotomy was performed which, however, did not reveal any visceral injury. Postoperatively, while the patient steadily recovered from
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Fig. 1 The external wounds caused by the bullet (arrows)
Fig. 3 The pseudoaneurysms (arrows) seen in the CT angiogram. Prior to this, there was a massive mediastinal widening and cardiomegaly in the chest X-ray on the 10th day, as shown in the inset
Fig. 2 The bullet (arrow) below the left hemidiaphragm. Inset shows the initial CT Scan of chest with only minimal fluid
Fig. 4 The anterior perforation, seen after evacuation of the hematoma. The same repaired with a PTFE patch (inset)
laparotomy, the X-ray showed gradual cardiomegaly and mediastinal widening. Moreover, after 12 days of convalescence, a pansystolic murmur was heard over the left lower sternal border. The patient was re-evaluated with an echo which, however, did not yield any new lesions. Then, a CECT of chest with 3-D reconstruction was obtained (Fig. 3). It showed two full thickness defects in the heart, each communicating with a pseudoaneurysm separately. One was overlying the interventricular septum, and the other was located in the inferior wall of the left ventricle, near the apex. The corresponding pseudoaneurysms were 6 9 6 and 4 9 4 cm, respectively (Fig. 4). Pleural effusion was also seen, more on the left. The patient was then
prepared for surgery with provisions for cardiopulmonary bypass (CPB). In the operation theater, the patient was intubated and monitoring lines were inserted. After heparinization, CPB was established via femoral artery and vein, as sternotomy could disrupt the pseudoaneurysms. The chest was then opened via median sternotomy and antegrade cardioplegic cardiac arrest was obtained. The entry wound was seen piercing the sternum laterally at the third intercostal level. The pseudoaneurysms sealing the perforations were evacuated. The first cardiac perforation was seen near the right ventricular (RV) outflow tract. It was a 1.5 9 1.5 cm defect overlying the ventricular septum just medial to left
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Gen Thorac Cardiovasc Surg
Discussion
Fig. 5 Diagrammatic representation of the intrathoracic trajectory of bullet (the thick black arrow). The base of heart and parts of the ventricular wall removed for clarity, and defects in inferior pericardium and diaphragm not shown. The inset shows the actual intracardiac passage of a cardiotomy sucker, with the left ventricular exit towards the right in the picture. RV right ventricle, LV left ventricle, VSD ventricular septal defect, IVS interventricular septum
anterior descending artery, resulting in a left ventricular (LV) opening, an RV opening and a ventricular septal defect (VSD) (Fig. 4). The VSD in our case was located on the anterosuperior surface of the septum, roofed only by anterior RV/LV wall. The bullet in fact pierced the anterior RV wall at its junction with the IVS, thereby creating a defect in RV/LV wall as well as the IVS. The second perforation was at the inferior wall of the LV, 3 cm off the apex. In line with these two, there was a 1 9 1 cm diaphragmatic perforation posteriorly and to the left (Fig. 5). Both the entry and the exit wounds and the VSD were repaired, after refreshing the edges, with polytetrafluoroethylene (PTFE) patches reinforced with pledgeted polyester sutures (Fig. 4). Patch closure was chosen as it was thought to be the best option available. The rent in the diaphragm was repaired primarily after refreshing the edges. After hemostasis and thorough irrigation, the patient was weaned from CPB uneventfully. Epicardial pacing wires, pleural and pericardial drains were placed, and the sternotomy and femoral access site were closed in standard fashion. The patient was extubated next morning, but he stayed in the ICU for 3 days, with inotropes tapered and stopped on the second postoperative day. The postoperative period was uneventful, apart from hypoproteinemia which was corrected by high protein diet. Postoperative echo at 2 weeks was normal. The mediastinal widening disappeared completely after 3 months of surgery. The patient is doing well at 2 years of follow up.
A vast majority of cardiac penetrating wounds are caused by stabs and firearms. Overall, cardiac gunshot wounds (GSW) are one of the most lethal injuries, with a reported case fatality rate of up to 80 % [4]. Most of them are rapidly fatal because of exsanguinations or tamponade, and the patients do not usually reach the place of care. Intermediate manifestations may be myocardial infarction with cardiogenic shock. Late manifestations of a cardiac GSW include endocarditis, pseudoaneurysm, VSD, recurrent pericarditis and valvular damage, which may develop as early as 1 month and as late as 21 years after the trauma [5]. Penetrating cardiac injuries may present initially in an unusual and insidious manner, and their diagnosis may not be immediately obvious [5]. Pseudoaneurysms are called acute when detected within 2 weeks of the traumatic event, during which time they are unpredictable and prone to fatal rupture. Chronic pseudoaneurysms are the ones detected after 3 months of the trauma [3]. The presence of a narrow orifice leading to a saccular cavity on transthoracic echocardiogram (TTE) distinguishes them from true aneurysms. In serial chest X-rays, progressive and rapid enlargement of cardiac silhouette is suspicious of the presence of pseudoaneurysms. Mass in chest X-ray may be found in as high as 50 % of the patients [3]. Cardiac along with coronary angiography is considered to be the best available test with highest diagnostic accuracy [3, 6]. Contrast-enhanced CT scan, with reconstructed images, like in our case, is also a preferred tool of investigation where conventional angiography may not be available. Transesophageal echo (TEE) and magnetic resonance imaging (MRI) have also been used, probably with better diagnostic yield than TTE [3]. In our case, initial evaluation was probably inadequate which led to the delay in diagnosis. Due to a high risk (30–45 %) of rupture, surgical treatment is recommended at diagnosis [3–5]. The surgical correction, however, itself has a high mortality rate exceeding 20 % [3]. Sharif et al. had reported probably the first case of survival after a bullet completely traversed the heart [7]. The present case was unique in two ways. First, there were two pseudoaneurysms and a VSD along the trajectory of the bullet. Second, unlike most of the penetrating cardiac wounds, the perforations were somehow sealed initially, and probably pre-existing focal pericardial adhesions may have played a role. The use of femoro-femoral approach for CPB and intensive postoperative care were important contributors to survival. In penetrating anterior chest injuries, one should have a high index of suspicion for cardiac injury and actually look for it.
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Gen Thorac Cardiovasc Surg Conflict of interest
None.
References 1. Kouchoukos NT, Blackstone EH, Hanley FL, Kirklin JK. Kirklin/ Barratt–Boyes cardiac surgery. 4th ed. Philadelphia: Saunders; 2013. 2. Asfaw I, Thoms NW, Arbulu A. Interventricular septal defects from penetrating injuries of the heart: a report of 12 cases and review of the literature. J Thorac Cardiovasc Surg. 1975;69:450.
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3. Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol. 1998;32:557–61. 4. Buckman RF, Badellino MM, Mauro LH, Asensio JA, Caputo C, Gass J. Penetrating cardiac wounds: prospective study of factors influencing initial resuscitation. J Trauma. 1993;34:717–25. 5. Fallah NM, Wallace HW, Su CC, Kutty AC, Blakemore WS. Unusual manifestations of penetrating cardiac injuries. Arch Surg. 1975;110:1357–62. 6. Treasure T. False aneurysm of the left ventricle. Heart. 1998; 80:7–8. 7. Omer A, Syed S, Khan G, Sharif H. Shot through the heart. Asian Cardiovasc Thorac Ann. 2006;14:443–4.
CASE REPORT
Traumatic pseudoaneurysm of the heart Ranjan Sapkota • Bhagawan Koirala
Received: 20 September 2013 / Accepted: 4 March 2014 Ó The Japanese Association for Thoracic Surgery 2014
Abstract Missile injuries to heart are one of the most severe penetrating chest injuries, and mostly fatal. The presentation in those who survive may be unusual and insidious. Pseudoaneurysms of the heart, usually sequel to myocardial infarction, may rarely present after penetrating cardiac wounds. Their management is a challenging one, and requires the provision of cardiopulmonary bypass. We report a case of ventricular pseudoaneurysm as a consequence of bullet injury, successfully managed in our center. Keywords
Heart Injury Pseudoaneurysm
Introduction It was in 1897 that Rehn first sutured a cardiac wound successfully [1]. Generally, a penetrating injury to the heart is considered potentially fatal. Patients with missile wounds of the heart are far less likely to survive than those with stab wounds [2]. Pseudoaneurysm of the heart is a rare condition that occurs when ventricular free wall rupture is contained by the surrounding adherent pericardium or scar tissue. Ventricular pseudoaneurysms usually occur after myocardial infarction, but can also be a sequel to cardiac surgery, trauma and infection [3]. Left ventricle is the most common site. Management of traumatic pseudoaneurysm of the heart is challenging and requires careful applications
R. Sapkota (&) B. Koirala Department of Cardio-Thoracic and Vascular Surgery, Manmohan Cardio-Thoracic Vascular and Transplant Center, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal e-mail: [email protected] B. Koirala e-mail: [email protected]
of principles of cardiac surgery. We report a similar case successfully managed at our center.
Case report A 32-year-old male was brought to the emergency room (ER) after 9 h of being shot from an intermediate range. He sustained injuries at his right lower jaw, chin and anterior chest. At presentation in ER, he was alert, hemodynamically stable and only complained of pain at the wound sites and upper abdomen. The 1 9 1 cm entry wound was on the right lower jaw, and there were two more wounds, both 1 9 1 cm, on the undersurface of the chin and left 3rd intercostal space just lateral to the midline (Fig. 1). Air entry was equal on both sides of the chest; heart sounds were normally heard, without any murmur, and neck veins were not engorged. Upper abdomen was slightly full and tender, with some guarding and rigidity. Chest X-ray showed the bullet below the left hemidiaphragm. The contrast-enhanced computed tomogram (CECT) of the chest showed the bullet impinging on the wall of the greater curvature of the stomach. Both the CECT and the Echocardiogram showed small pericardial effusion, without features of tamponade (Fig. 2). There was no subcutaneous emphysema or pneumothorax, both clinically as well as radiologically. Thus in the first evaluation the injury to esophagus and airway were reasonably ruled out. Cardiac injury was also thought to be absent in view of small, non-progressing effusion, and absence of any hemodynamic compromise or tamponade. But in view of subtly progressing peritonitis and with the bullet in the abdomen, a quick laparotomy was performed which, however, did not reveal any visceral injury. Postoperatively, while the patient steadily recovered from
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Gen Thorac Cardiovasc Surg
Fig. 1 The external wounds caused by the bullet (arrows)
Fig. 3 The pseudoaneurysms (arrows) seen in the CT angiogram. Prior to this, there was a massive mediastinal widening and cardiomegaly in the chest X-ray on the 10th day, as shown in the inset
Fig. 2 The bullet (arrow) below the left hemidiaphragm. Inset shows the initial CT Scan of chest with only minimal fluid
Fig. 4 The anterior perforation, seen after evacuation of the hematoma. The same repaired with a PTFE patch (inset)
laparotomy, the X-ray showed gradual cardiomegaly and mediastinal widening. Moreover, after 12 days of convalescence, a pansystolic murmur was heard over the left lower sternal border. The patient was re-evaluated with an echo which, however, did not yield any new lesions. Then, a CECT of chest with 3-D reconstruction was obtained (Fig. 3). It showed two full thickness defects in the heart, each communicating with a pseudoaneurysm separately. One was overlying the interventricular septum, and the other was located in the inferior wall of the left ventricle, near the apex. The corresponding pseudoaneurysms were 6 9 6 and 4 9 4 cm, respectively (Fig. 4). Pleural effusion was also seen, more on the left. The patient was then
prepared for surgery with provisions for cardiopulmonary bypass (CPB). In the operation theater, the patient was intubated and monitoring lines were inserted. After heparinization, CPB was established via femoral artery and vein, as sternotomy could disrupt the pseudoaneurysms. The chest was then opened via median sternotomy and antegrade cardioplegic cardiac arrest was obtained. The entry wound was seen piercing the sternum laterally at the third intercostal level. The pseudoaneurysms sealing the perforations were evacuated. The first cardiac perforation was seen near the right ventricular (RV) outflow tract. It was a 1.5 9 1.5 cm defect overlying the ventricular septum just medial to left
123
Gen Thorac Cardiovasc Surg
Discussion
Fig. 5 Diagrammatic representation of the intrathoracic trajectory of bullet (the thick black arrow). The base of heart and parts of the ventricular wall removed for clarity, and defects in inferior pericardium and diaphragm not shown. The inset shows the actual intracardiac passage of a cardiotomy sucker, with the left ventricular exit towards the right in the picture. RV right ventricle, LV left ventricle, VSD ventricular septal defect, IVS interventricular septum
anterior descending artery, resulting in a left ventricular (LV) opening, an RV opening and a ventricular septal defect (VSD) (Fig. 4). The VSD in our case was located on the anterosuperior surface of the septum, roofed only by anterior RV/LV wall. The bullet in fact pierced the anterior RV wall at its junction with the IVS, thereby creating a defect in RV/LV wall as well as the IVS. The second perforation was at the inferior wall of the LV, 3 cm off the apex. In line with these two, there was a 1 9 1 cm diaphragmatic perforation posteriorly and to the left (Fig. 5). Both the entry and the exit wounds and the VSD were repaired, after refreshing the edges, with polytetrafluoroethylene (PTFE) patches reinforced with pledgeted polyester sutures (Fig. 4). Patch closure was chosen as it was thought to be the best option available. The rent in the diaphragm was repaired primarily after refreshing the edges. After hemostasis and thorough irrigation, the patient was weaned from CPB uneventfully. Epicardial pacing wires, pleural and pericardial drains were placed, and the sternotomy and femoral access site were closed in standard fashion. The patient was extubated next morning, but he stayed in the ICU for 3 days, with inotropes tapered and stopped on the second postoperative day. The postoperative period was uneventful, apart from hypoproteinemia which was corrected by high protein diet. Postoperative echo at 2 weeks was normal. The mediastinal widening disappeared completely after 3 months of surgery. The patient is doing well at 2 years of follow up.
A vast majority of cardiac penetrating wounds are caused by stabs and firearms. Overall, cardiac gunshot wounds (GSW) are one of the most lethal injuries, with a reported case fatality rate of up to 80 % [4]. Most of them are rapidly fatal because of exsanguinations or tamponade, and the patients do not usually reach the place of care. Intermediate manifestations may be myocardial infarction with cardiogenic shock. Late manifestations of a cardiac GSW include endocarditis, pseudoaneurysm, VSD, recurrent pericarditis and valvular damage, which may develop as early as 1 month and as late as 21 years after the trauma [5]. Penetrating cardiac injuries may present initially in an unusual and insidious manner, and their diagnosis may not be immediately obvious [5]. Pseudoaneurysms are called acute when detected within 2 weeks of the traumatic event, during which time they are unpredictable and prone to fatal rupture. Chronic pseudoaneurysms are the ones detected after 3 months of the trauma [3]. The presence of a narrow orifice leading to a saccular cavity on transthoracic echocardiogram (TTE) distinguishes them from true aneurysms. In serial chest X-rays, progressive and rapid enlargement of cardiac silhouette is suspicious of the presence of pseudoaneurysms. Mass in chest X-ray may be found in as high as 50 % of the patients [3]. Cardiac along with coronary angiography is considered to be the best available test with highest diagnostic accuracy [3, 6]. Contrast-enhanced CT scan, with reconstructed images, like in our case, is also a preferred tool of investigation where conventional angiography may not be available. Transesophageal echo (TEE) and magnetic resonance imaging (MRI) have also been used, probably with better diagnostic yield than TTE [3]. In our case, initial evaluation was probably inadequate which led to the delay in diagnosis. Due to a high risk (30–45 %) of rupture, surgical treatment is recommended at diagnosis [3–5]. The surgical correction, however, itself has a high mortality rate exceeding 20 % [3]. Sharif et al. had reported probably the first case of survival after a bullet completely traversed the heart [7]. The present case was unique in two ways. First, there were two pseudoaneurysms and a VSD along the trajectory of the bullet. Second, unlike most of the penetrating cardiac wounds, the perforations were somehow sealed initially, and probably pre-existing focal pericardial adhesions may have played a role. The use of femoro-femoral approach for CPB and intensive postoperative care were important contributors to survival. In penetrating anterior chest injuries, one should have a high index of suspicion for cardiac injury and actually look for it.
123
Gen Thorac Cardiovasc Surg Conflict of interest
None.
References 1. Kouchoukos NT, Blackstone EH, Hanley FL, Kirklin JK. Kirklin/ Barratt–Boyes cardiac surgery. 4th ed. Philadelphia: Saunders; 2013. 2. Asfaw I, Thoms NW, Arbulu A. Interventricular septal defects from penetrating injuries of the heart: a report of 12 cases and review of the literature. J Thorac Cardiovasc Surg. 1975;69:450.
123
3. Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol. 1998;32:557–61. 4. Buckman RF, Badellino MM, Mauro LH, Asensio JA, Caputo C, Gass J. Penetrating cardiac wounds: prospective study of factors influencing initial resuscitation. J Trauma. 1993;34:717–25. 5. Fallah NM, Wallace HW, Su CC, Kutty AC, Blakemore WS. Unusual manifestations of penetrating cardiac injuries. Arch Surg. 1975;110:1357–62. 6. Treasure T. False aneurysm of the left ventricle. Heart. 1998; 80:7–8. 7. Omer A, Syed S, Khan G, Sharif H. Shot through the heart. Asian Cardiovasc Thorac Ann. 2006;14:443–4.
