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ISSN (On-line): 1678-9741 Impact Factor: 0.809
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Volume 33 Number 1, January - February, 2018

REVIEW ARTICLE

DOI: http://dx.doi.org/10.21470/1678-9741-2017-0150

The Role of Heart Team Approach in Penetrating Cardiac Trauma: Case Report and Review of the Literature

Marzia CottiniI; Amedeo PergoliniI; Federico RanocchiI; Francesco MusumeciI

IDepartment of Heart and Vessels, Cardiac Surgery Unit and Heart Transplantation Center, "S. Camillo-Forlanini" Hospital, Rome, Italy.

This study was carried out at the Department of Heart and Vessels, Cardiac Surgery Unit and Heart Transplantation Center, "S. Camillo-Forlanini" Hospital, Rome, Italy.

Correspondence To:
Marzia Cottini
Department of Heart and Vessels, Cardiac Surgery Unit and Heart Transplantation
Center, “S. Camillo-Forlanini” Hospital – Circonvallazione Gianicolense – Rome, Italy
E-mail: marzia.cottini@gmail.com

ABSTRACT
Penetrating cardiac trauma has been increasing in clinical experience and is joined to important morbidity and mortality. A case of a 38-year-old female with history of postpartum depression was reported, admitted to our department for cardiac tamponade due to penetrating self-inflicted multiple stab wound of the chest complicated by rupture of anterior left ventricular wall and traumatic ventricular septal defect. Following the unstable hemodynamic instability, a combined therapeutic strategy was chosen: surgery and transcatheter implantation to correct free wall ventricle damage and traumatic ventricular septal defect, respectively.

Keywords Wounds, Penetrating. Heart septal defects, ventricular. Cardiac tamponade. Cardiac surgical procedures. Heart injuries. Septal occluder device

ABBREVIATIONS AND ACRONYMS

CVP = American Heart Association

ECG = American Stroke Association

TTE = Confidence interval

tVSD = Literatura Latino-Americana em Ciências da Saúde

VSD = Medical Subject Headings

INTRODUCTION

A very rare and uncommon case of penetrating cardiac injuries was reported, due to multiple self-inflicted stabs in a young female with a history of postpartum depression and causing cardiac tamponade due to free ventricular wall rupture and iatrogenic ventricular septal defect. The particularity of combined therapeutic choices in the same time - surgical drainage of blood pericardial effusion and endovascular closure of traumatic ventricular septal defect (tVSD) with ventricular septal defect (VSD) occluder device - was described.

CASE REPORT

A case of a 38-year-old female with a history of post-partum depression was presented, referring to our hospital for penetrating self-inflicted multiple stab wounds of the chest. Vital signs of arrival were systolic blood pressure of 80/45 mmHg, tachypnea (30 breaths/min) with low oxygen saturation (89%), cyanosis and jugular vein distension (central venous pressure of 15-16 cmH2O). The echocardiography (ECG) documented raised ST, J waves. The fast-transthoracic echocardiogram (TTE) revealed a cardiac tamponade (maximum diameter 3.2 cm) and a VSD (about 1.5-1.8 cm from left ventricle side) with ventricular left-right shunt (Qp:Qs=2, Figures 1A to D). Following the critical hemodynamic deterioration, the norepinephrine and epinephrine infusions were started (0.1 mcg/kg/min) and the patient was immediately operated. Combined unusual therapeutic strategy has been chosen: surgery for the pericardial effusion drainage and control of the ventricular wall wounds, and transcatheter closure of the tVSD. Median sternotomy and a T-inverted pericardiotomy were performed to remove all clots and pericardial effusion from mediastinum. After the detection of the heart, we found a single left ventricle anterior wall wound, hence we directly closed with a direct suture (3-0 prolene with Teflon pledgets). To complete the treatment, the patient underwent a procedure to position the Amplatzer VSD occluder device (16-mm) by transcatheter way in the same operation time (Figures 1E to F and Figure 2B). The procedures were free of complications and the postoperative period was short and uneventfully. She was discharged on the 10th postoperative day with single antiaggregation therapy and was followed-up by psychological support service.

Fig. 1 - Transthoracic echocardiography, parasternal view showing interventricular traumatic defect in the median septum (a), and evidence of left-to-right shunt (b). Transthoracic echocardiography, apical view of iatrogenic interventricular defect (c) and color-doppler image of the L-R shunt (d). Transthoracic echocardiography, longitudinal view of the successful implanting Amplatzer device to close the tVSD (e-f ).

Fig. 2 - Conventional coronary angiography documented traumatic ventricular septal defect (a) and positioning of VSD occluder (white arrow) with good results (b).

DISCUSSION

The major cardiac injuries could be blunt or penetrating. Penetrating cardiac trauma has different and several presentations[1-10]. The patient could be presented with a stable tamponade (hypotension, elevated central venous pressure [CVP]) or unstable ones (shock with critical hypotension, tachycardia, dyspnoea, raised CVP, pulsus paradoxus with distant heart sounds and impalpable apex). Our patient fitted in the unstable patient type: the decision needed to be made very quickly[7-15]. The first step was the diagnostic workout (chest X-ray, ECG, computed tomography scan, TTE) that identify and describe the size, type and setting of the lesion and general assessment. In our case, the patient had a cardiac tamponade due to stab complicated to iatrogenic VSD. Therefore, we decided to proceed with combined therapeutic path in the same time: 1) surgical approach to suture ventricular wound and 2) endovascular approach to close iatrogenic VSD with an occluder device. This case is the first reported in scientific literature because the most of the previous article describe single procedure for closure of VSD with occluder device after surgery or only endovascular approach or first endovascular and then surgery correction, but there are not combined procedures in the same time (Table 1), following some of the most important experience in the literature. According to Degiannis et al.[21], surgical approach could be fundamental and the primary step to control the bleeding, in particularly the best is median sternotomy approach which gives an effective and extensive vision of heart, great vessels, to other structures in the mediastinum and to both pleural cavities[1-9,13-16]. On the other hand, left antero-lateral thoracotomy provides rapid access to the right and left ventricles and to the pulmonary artery; this is our approach of choice for emergency room thoracotomy[21]. In case of penetrating cardiac injuries complicated by iatrogenic VSD, the combined therapeutic choice with surgery and percutaneous device was described by Argento et al.[12], in 2002. Afterwards, only three cases by Berry et al.[13] and Ali et al.[17], with good results (low postoperative recovery, total cardiac function restore without any interventricular septum shunt) were published. The use of minimally surgery (opening, controlling and treating the cause of bleeding) associated with the percutaneous occluder device implantation in penetrating cardiac injuries with iatrogenic VSD may be a complete and safe approach to this trauma patient. The tVSD exclusion by percutaneous device avoided long surgical timing hence less invasiveness, no cardiopulmonary bypass, less anesthesia time and recovery time.

Table 1 - Review of previous ventricular septal defect (VSD) after cardiac wound stab described in scientific literature and their treatments. The traumatic VSD was diagnosed immediately, deferred VSD diagnosis was not considered.
Author Year Type of Paper Patient Gender Complication Therapeutic choice
Lui et al.[1] 1965 CR 1 Male Cardiac tamponade Surgery
Pejaković & Mileusnić[2] 1967 CR 1 Male Cardiac tamponade Surgery
Kieny et al.[3] 1975 CR 1 Male Cardiac tamponade Surgery
Asfaw et al.[4] 1975 RL 12 Male HF, injury of tricuspid valve, injury of left anterior descending coronary artery Surgery
Bande et al.[5] 1980 CR and RL 1 Male Cardiac tamponade Surgery
Bryan et al.[6] 1988 CR 1 Male Cardiac tamponade Surgery
Voronov et al.[7] 1989 CR 1 Male Cardiac tamponade Surgery, suture
Take et al.[8] 1993 CR 1 Female Rupture of papillary muscle Surgery
Carvalho et al.[9] 1994 CR 1 Male Hemothorax Surgery, patch suture
Doty et al.[10] 1999 CR 1 Male Tricuspid valve injury Surgery
Gölbasi et al.[11] 2001 CR 1 Male Cardiac tamponade Surgery, suture
Argento et al.[12] 2002 CR 1 Male Cardiac tamponade Thoracotomy and percutaneous device
Berry et al.[13] 2006 CR 1 Male Cardiac tamponade Surgery and percutaneous device
Topaloglu et al.[14] 2006 CR 1 Male Cardiac tamponade Surgery
Choi et al.[15] 2008 CR and RL 1 Male Atrioventricular valves rupture Surgery
Antoniades et al.[16] 2011 CR 1 Female Pneumothorax and cardiac tamponade Surgery
Ali et al.[17] 2013 CR 1 Male Cardiac tamponade Surgery and percutaneous device
Caffery et al.[18] 2014 CR 1 Male Hemothorax Percutaneous device then surgery
Tang et al.[19] 2016 CR 1 Male Congestive heart failure Percutaneous device then surgery
Kharwar et al.[20] 2016 CR 1 Male Cardiac tamponade Percutaneous device
Cottini et al. (reported case) 2018 CR and RL 1 Female Cardiac tamponade Surgery and percutaneous device

CR=case report; RL=review of the literature; HF=heart failure

Table 1 - Review of previous ventricular septal defect (VSD) after cardiac wound stab described in scientific literature and their treatments. The traumatic VSD was diagnosed immediately, deferred VSD diagnosis was not considered.

CONCLUSION

The combined therapeutic choice of surgery and interventional approach in case of penetrating cardiac trauma with limited tVSD is indicated and optimal for rapid clinical stabilization.

The rapid and early diagnosis associated with an organized and available cardiac staff (interventional cardiologists and cardiac surgeons) may be a productive collaboration.

ACKNOWLEDGEMENTS

We thank Dr. Violini and his staff for the VSD occluder implantation in our patient which greatly improved the case.


REFERENCES

1. Lui AH, Glas WW, Bercu BA. Stab wound of the heart with tamponadeand interventricular septal defect. Report of a case. J Thorac Cardiovasc Surg.1965;49:517-22.

2. Pejaković S, Mileusnić S. Interventricular defect ofthe septum caused by a stab wound of the heart. Srp Arh Celok Lek.1967;95(1):75-9.

3. Kieny R, Wolff F, Gross A, Mantz JM, Kurtz T, Kieny MT.Post-traumatic interventricular communication. Closure under extracorporealcirculation. Arch Mal Coeur Vaiss. 1975;68(1):97-103. [MedLine]

4. Asfaw I, Thoms NW, Arbulu A. Interventricular septal defects frompenetrating injuries of the heart: a report of 12 cases and review of theliterature. J Thorac Cardiovasc Surg. 1975;69(3):450-7.

5. Bande A, Pisano GF, Sanna A, Scano F, Binaghi F. Interventricularcommunication secondary to a penetrating heart wound. A case description; areview of the literature. Minerva Cardioangiol.1980;28(7-8):543-6.

6. Bryan AJ, Angelini GD, Breckenridge IM. Spontaneous closure of atraumatic interventricular septal defect following a penetrating chest injury.Thorac Cardiovasc Surg. 1988;36(3):172-3.

7. Voronov AA, Kuksinskiĭ VE, Il'in AS. Surgical treatment of atraumatic defect of the interventricular septum after a knife wound of theheart. Grudn Khir. 1989;5:90-1.

8. Take A, Yamaguchi T, Horimi H, Kato M, Hasegawa T, Kimura S. Bluntcardiac trauma resulting in ventricular septal perforation and mitralregurgitation due to papillary muscle rupture: a case report. Nihon Kyobu GekaGakkai Zasshi. 1993;41(1):119-25.

9. Carvalho AC, Echeverria NG, Gonçalves R, Telles CA, Andrade JC,Buffolo E. Late development of congestive heart failure in interventricularcommunication caused by penetrating wound, with pulmonary hypertensionresolution after surgical correction. Arq Bras Cardiol.1994;62(2):119-21.

10. Doty JR, Cameron DE, Elmaci T, Salomon NW. Penetrating trauma to thetricuspid valve and ventricular septum: delayed repair. Ann Thorac Surg.1999;67(1):252-3.

11. Gölbaşi Z, Ciçek D, Uçar O, Kaya D, Keleş T,Ciçekçiolu H, et al. Traumatic ventricular septal defect and mitralinsufficiency after a Kebab's shish wound to the chest. Eur J Echocardiogr.2001;2(3):203-4.

12. Argento G, Fiorilli R, Del Prete G. A rare case of a post-traumaticintraventricular defect. Ital Heart J Suppl. 2002;3(3):352-4.

13. Berry C, Hillis WS, Knight WB. Transcatheter closure of aventricular septal defect resulting from knife stabbing using the Amplatzermuscular VSD occluder. Catheter Cardiovasc Interv.2006;68(1):153-6.

14. Topaloglu S, Aras D, Cagli K, Ergun K, Deveci B, Demir AD, et al.Penetrating trauma to the mitral valve and ventricular septum. Tex Heart Inst J.2006;33(3):392-5.

15. Choi JS, Kim EJ. Simultaneous rupture of the mitral and tricuspidvalves with left ventricular rupture caused by blunt trauma. Ann Thorac Surg.2008;86(4):1371-3.

16. Antoniades L, Petrou PM, Eftychiou C, Nicolaides E. Penetratingheart injury resulting in ventricular septal defect. Hellenic J Cardiol.2011;52(1):71-4.

17. Ali TA, Fatimi SH, Hasan BS. Transcatheter closure of a traumaticventricular septal defect using an Amplatzer(tm) atrial septal occluder device.Catheter Cardiovasc Interv. 2013;82(4):569-73.

18. Caffery T, Robinson D, O'Neal H, Kahn A, Thurston S, Musso M.Delayed detection of a ventricular septal defect following penetrating trauma. JLa State Med Soc. 2014;166(6):239-41.

19. Tang L, Tang JJ, Fang ZF, Hu XQ, Shen XQ, Zhou SH. Severe mechanicalhemolysis after transcatheter closure of a traumatic ventricular septal defectusing the Amplatzer atrial septal occluder. Int Heart J.2016;57(4):519-21.

20. Kharwar RB, Madan T, Thakkar B, Shukla A, Deshmukh J. Percutaneousdevice closure of post-traumatic ventricular septal rupture. JACC CardiovascInterv. 2016;9(17):1848-50.

21. Degiannis E, Bowley DM, Westaby S. Penetrating cardiac injury. Ann RColl Surg Engl. 2005;87(1):61-3.

No financial support.
No conflict of interest

Authors' roles & responsibilities

MC First Author, revision and corresponding author; final approval of the version to be published

AP Writting and revision; final approval of the version to be published

FR Revising; final approval of the version to be published

FM Revised critically; final approval of the version to be published

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