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• W2027517323 abstract "Traumatic ventricular septal defect is an uncommon complication of blunt chest trauma. We report a case of ventricular septal avulsion, associated with traumatic ventricular septal defect and the associated management concerns. Traumatic ventricular septal defect is an uncommon complication of blunt chest trauma. We report a case of ventricular septal avulsion, associated with traumatic ventricular septal defect and the associated management concerns. Traumatic ventricular septal defects (VSDs) have a reported 5.5% incidence after blunt chest trauma [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar]. High-speed motor vehicle accidents (MVA) are the most common cause of this injury [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar]. They may present immediately or several days after the initial trauma. This injury can be diagnosed by echocardiogram, which should be performed in patients with a new onset murmur or hemodynamic instability after blunt chest trauma. Here we report an unusual case of VSD in association with ventricular septal avulsion after a motor vehicle accident. In this child, a portion of the septal wall was avulsed but remained attached to the septal wall with an echocardiographic appearance that was very concerning for possible embolization in the left ventricular outflow tract (LVOT).A 15-year-old restrained passenger sustained blunt chest trauma in a high-speed motor vehicle accident (MVA), with brief loss of consciousness. Paramedics found him conscious and sitting by the vehicle. He was emergently transferred after an echocardiogram revealed a small, muscular VSD and a hypermobile “thrombus” in the LVOT. He arrived hemodynamically stable, complaining of headache, pain over his left chest, and shoulder contusions. He was dyspneic with hemoptysis productive of small clots. Breath sounds were coarse and diminished on the left. A grade III/VI holosystolic murmur was heard over the cardiac apex. Chest X-ray revealed a left third rib fracture and a left pulmonary contusion. Electrocardiogram revealed normal sinus rhythm with diffuse ST segment elevation in the anterolateral and inferior leads. The first troponin-I level was 40 ng/mL and fell quickly on serial evaluation. Echocardiographically, as we examined this thrombus moving in and out of the LVOT (Fig 1A-C) , we grew suspicious that its contour matched the contour of the irregular defect seen in the left ventricular septum (Fig 1A). There was also a small mid-muscular VSD shunting left to right (Fig 1D) with an irregular channel (Fig 1E) that differed in character from congenital or postinfarction VSDs. A chest tube was placed on hospital day 2 for stable hemothorax. On day 3, flexible bronchoscopy was performed for left lung atelectasis, which resolved after the extraction of a large bloody mucous plug from the left mainstem bronchus. Hemoptysis slowly improved over the next 11 days. Serial echocardiograms were remarkable only for the slow evolution of a small pericardial effusion.On day 13, surgery revealed 200 cc of bloody pericardial fluid and soft pericardial adhesions. After cardioplegia, the aorta was opened and the septal avulsion was excised through the aortic valve. It was firmly attached and pink (Fig 1F). The VSD was closed through the tricuspid valve with autologous fixed pericardium. Large bites were taken through the rim of the friable VSD. Echo revealed no residual VSD. The patient was extubated on the table and discharged in 5 days. Later, a small VSD patch leak was noted and resolved on follow-up.CommentCardiac injury occurs in 20% of high-speed MVAs with blunt chest trauma [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar]. Though most are cardiac contusions, traumatic VSDs present in 2% to 10% of blunt chest trauma cases from MVAs [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar]. They are more common in children and adolescents, probably from the pliability of the immature chest wall [3Stamm C. Feit L.R. Geva T. del Nido P.J. Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma.Eur J Cardiothorac Surg. 2002; 22: 154-156Crossref PubMed Scopus (13) Google Scholar]. They result from compression of the heart between the chest wall and the spine, usually from rapid deceleration. In the course of the cardiac cycle, full ventricles with closed atrioventricular valves make the heart most susceptible to increases in intraventricular pressure that can rupture the septum [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 3Stamm C. Feit L.R. Geva T. del Nido P.J. Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma.Eur J Cardiothorac Surg. 2002; 22: 154-156Crossref PubMed Scopus (13) Google Scholar, 4Amorim M.J. Almeida J. Santos A. Bastos P.T. Atrioventricular septal defect following blunt chest trauma.Eur J Cardiothorac Surg. 1999; 16: 679-682Crossref PubMed Scopus (14) Google Scholar]. Apical muscular VSDs are most common, and subpulmonic and infundibular defects less so [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar].Although most traumatic VSDs occur immediately, delayed onset from hours to weeks after trauma can occur, and are thought to result from myocardial injury followed by microvascular disruption followed by liquefaction necrosis and VSD formation [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 4Amorim M.J. Almeida J. Santos A. Bastos P.T. Atrioventricular septal defect following blunt chest trauma.Eur J Cardiothorac Surg. 1999; 16: 679-682Crossref PubMed Scopus (14) Google Scholar]. Appearance of a murmur is correspondingly delayed [5Rootman D.B. Latter D. Ahmed N. Case report of ventricular septal defect secondary to blunt chest trauma.Can J Surg. 2007; 50: 227-228PubMed Google Scholar]. Symptoms vary with size of the VSD but most commonly include dyspnea, a new systolic murmur, cardiomegaly, and congestive heart failure [6Sugiyama G. Lau C. Tak V. Lee D.C. Burak J. Traumatic ventricular septal defect.Ann Thorac Surg. 2011; 91: 908-910Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar]. If the VSD is large, hemodynamic decompensation and death can occur rapidly. Echocardiography is the diagnostic mainstay and is reliable, noninvasive, and easily repeated for changes in status, a new murmur, or before discharge. The location, size, and hemodynamic impact of the VSD should be assessed.While traumatic VSD is well described, to our knowledge this is the first reported case of ventricular septal avulsion. The management is usually guided by the size of the VSD. Patients with small shunts (pulmonary-to-systemic flow ratio [Qp:Qs] < 1.5:1) like this child can usually be managed medically. Device closure may have been possible here had it not been for the hypermobile flap of avulsed septal muscle prolapsing ominously through the aortic valve. Any rush to repair was tempered by the patient's head trauma (loss of consciousness), and pulmonary contusion with active hemoptysis. Because the attachment of the flap seemed thick at its base, and we deduced it to be muscle, we were somewhat reassured to allow the hemoptysis to clear preoperatively. Our suspicions were confirmed at surgery and the patient recovered quickly. Traumatic ventricular septal defects (VSDs) have a reported 5.5% incidence after blunt chest trauma [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar]. High-speed motor vehicle accidents (MVA) are the most common cause of this injury [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar]. They may present immediately or several days after the initial trauma. This injury can be diagnosed by echocardiogram, which should be performed in patients with a new onset murmur or hemodynamic instability after blunt chest trauma. Here we report an unusual case of VSD in association with ventricular septal avulsion after a motor vehicle accident. In this child, a portion of the septal wall was avulsed but remained attached to the septal wall with an echocardiographic appearance that was very concerning for possible embolization in the left ventricular outflow tract (LVOT). A 15-year-old restrained passenger sustained blunt chest trauma in a high-speed motor vehicle accident (MVA), with brief loss of consciousness. Paramedics found him conscious and sitting by the vehicle. He was emergently transferred after an echocardiogram revealed a small, muscular VSD and a hypermobile “thrombus” in the LVOT. He arrived hemodynamically stable, complaining of headache, pain over his left chest, and shoulder contusions. He was dyspneic with hemoptysis productive of small clots. Breath sounds were coarse and diminished on the left. A grade III/VI holosystolic murmur was heard over the cardiac apex. Chest X-ray revealed a left third rib fracture and a left pulmonary contusion. Electrocardiogram revealed normal sinus rhythm with diffuse ST segment elevation in the anterolateral and inferior leads. The first troponin-I level was 40 ng/mL and fell quickly on serial evaluation. Echocardiographically, as we examined this thrombus moving in and out of the LVOT (Fig 1A-C) , we grew suspicious that its contour matched the contour of the irregular defect seen in the left ventricular septum (Fig 1A). There was also a small mid-muscular VSD shunting left to right (Fig 1D) with an irregular channel (Fig 1E) that differed in character from congenital or postinfarction VSDs. A chest tube was placed on hospital day 2 for stable hemothorax. On day 3, flexible bronchoscopy was performed for left lung atelectasis, which resolved after the extraction of a large bloody mucous plug from the left mainstem bronchus. Hemoptysis slowly improved over the next 11 days. Serial echocardiograms were remarkable only for the slow evolution of a small pericardial effusion. On day 13, surgery revealed 200 cc of bloody pericardial fluid and soft pericardial adhesions. After cardioplegia, the aorta was opened and the septal avulsion was excised through the aortic valve. It was firmly attached and pink (Fig 1F). The VSD was closed through the tricuspid valve with autologous fixed pericardium. Large bites were taken through the rim of the friable VSD. Echo revealed no residual VSD. The patient was extubated on the table and discharged in 5 days. Later, a small VSD patch leak was noted and resolved on follow-up. CommentCardiac injury occurs in 20% of high-speed MVAs with blunt chest trauma [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar]. Though most are cardiac contusions, traumatic VSDs present in 2% to 10% of blunt chest trauma cases from MVAs [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar]. They are more common in children and adolescents, probably from the pliability of the immature chest wall [3Stamm C. Feit L.R. Geva T. del Nido P.J. Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma.Eur J Cardiothorac Surg. 2002; 22: 154-156Crossref PubMed Scopus (13) Google Scholar]. They result from compression of the heart between the chest wall and the spine, usually from rapid deceleration. In the course of the cardiac cycle, full ventricles with closed atrioventricular valves make the heart most susceptible to increases in intraventricular pressure that can rupture the septum [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 3Stamm C. Feit L.R. Geva T. del Nido P.J. Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma.Eur J Cardiothorac Surg. 2002; 22: 154-156Crossref PubMed Scopus (13) Google Scholar, 4Amorim M.J. Almeida J. Santos A. Bastos P.T. Atrioventricular septal defect following blunt chest trauma.Eur J Cardiothorac Surg. 1999; 16: 679-682Crossref PubMed Scopus (14) Google Scholar]. Apical muscular VSDs are most common, and subpulmonic and infundibular defects less so [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar].Although most traumatic VSDs occur immediately, delayed onset from hours to weeks after trauma can occur, and are thought to result from myocardial injury followed by microvascular disruption followed by liquefaction necrosis and VSD formation [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 4Amorim M.J. Almeida J. Santos A. Bastos P.T. Atrioventricular septal defect following blunt chest trauma.Eur J Cardiothorac Surg. 1999; 16: 679-682Crossref PubMed Scopus (14) Google Scholar]. Appearance of a murmur is correspondingly delayed [5Rootman D.B. Latter D. Ahmed N. Case report of ventricular septal defect secondary to blunt chest trauma.Can J Surg. 2007; 50: 227-228PubMed Google Scholar]. Symptoms vary with size of the VSD but most commonly include dyspnea, a new systolic murmur, cardiomegaly, and congestive heart failure [6Sugiyama G. Lau C. Tak V. Lee D.C. Burak J. Traumatic ventricular septal defect.Ann Thorac Surg. 2011; 91: 908-910Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar]. If the VSD is large, hemodynamic decompensation and death can occur rapidly. Echocardiography is the diagnostic mainstay and is reliable, noninvasive, and easily repeated for changes in status, a new murmur, or before discharge. The location, size, and hemodynamic impact of the VSD should be assessed.While traumatic VSD is well described, to our knowledge this is the first reported case of ventricular septal avulsion. The management is usually guided by the size of the VSD. Patients with small shunts (pulmonary-to-systemic flow ratio [Qp:Qs] < 1.5:1) like this child can usually be managed medically. Device closure may have been possible here had it not been for the hypermobile flap of avulsed septal muscle prolapsing ominously through the aortic valve. Any rush to repair was tempered by the patient's head trauma (loss of consciousness), and pulmonary contusion with active hemoptysis. Because the attachment of the flap seemed thick at its base, and we deduced it to be muscle, we were somewhat reassured to allow the hemoptysis to clear preoperatively. Our suspicions were confirmed at surgery and the patient recovered quickly. Cardiac injury occurs in 20% of high-speed MVAs with blunt chest trauma [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar]. Though most are cardiac contusions, traumatic VSDs present in 2% to 10% of blunt chest trauma cases from MVAs [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar]. They are more common in children and adolescents, probably from the pliability of the immature chest wall [3Stamm C. Feit L.R. Geva T. del Nido P.J. Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma.Eur J Cardiothorac Surg. 2002; 22: 154-156Crossref PubMed Scopus (13) Google Scholar]. They result from compression of the heart between the chest wall and the spine, usually from rapid deceleration. In the course of the cardiac cycle, full ventricles with closed atrioventricular valves make the heart most susceptible to increases in intraventricular pressure that can rupture the septum [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 3Stamm C. Feit L.R. Geva T. del Nido P.J. Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma.Eur J Cardiothorac Surg. 2002; 22: 154-156Crossref PubMed Scopus (13) Google Scholar, 4Amorim M.J. Almeida J. Santos A. Bastos P.T. Atrioventricular septal defect following blunt chest trauma.Eur J Cardiothorac Surg. 1999; 16: 679-682Crossref PubMed Scopus (14) Google Scholar]. Apical muscular VSDs are most common, and subpulmonic and infundibular defects less so [2Ozay B. Ozer N. Ketenci B. Demirtas M. Unsuspected location of a ventricular septal defect after blunt chest trauma.Thorac Cardiovasc Surg. 2008; 56: 110-111Crossref PubMed Scopus (7) Google Scholar]. Although most traumatic VSDs occur immediately, delayed onset from hours to weeks after trauma can occur, and are thought to result from myocardial injury followed by microvascular disruption followed by liquefaction necrosis and VSD formation [1Olsovsky M.R. Topaz O. DiSciascio G. Vetrovec G.W. Acute traumatic ventricular septal rupture.Am Heart J. 1996; 131: 1039-1041Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 4Amorim M.J. Almeida J. Santos A. Bastos P.T. Atrioventricular septal defect following blunt chest trauma.Eur J Cardiothorac Surg. 1999; 16: 679-682Crossref PubMed Scopus (14) Google Scholar]. Appearance of a murmur is correspondingly delayed [5Rootman D.B. Latter D. Ahmed N. Case report of ventricular septal defect secondary to blunt chest trauma.Can J Surg. 2007; 50: 227-228PubMed Google Scholar]. Symptoms vary with size of the VSD but most commonly include dyspnea, a new systolic murmur, cardiomegaly, and congestive heart failure [6Sugiyama G. Lau C. Tak V. Lee D.C. Burak J. Traumatic ventricular septal defect.Ann Thorac Surg. 2011; 91: 908-910Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar]. If the VSD is large, hemodynamic decompensation and death can occur rapidly. Echocardiography is the diagnostic mainstay and is reliable, noninvasive, and easily repeated for changes in status, a new murmur, or before discharge. The location, size, and hemodynamic impact of the VSD should be assessed. While traumatic VSD is well described, to our knowledge this is the first reported case of ventricular septal avulsion. The management is usually guided by the size of the VSD. Patients with small shunts (pulmonary-to-systemic flow ratio [Qp:Qs] < 1.5:1) like this child can usually be managed medically. Device closure may have been possible here had it not been for the hypermobile flap of avulsed septal muscle prolapsing ominously through the aortic valve. Any rush to repair was tempered by the patient's head trauma (loss of consciousness), and pulmonary contusion with active hemoptysis. Because the attachment of the flap seemed thick at its base, and we deduced it to be muscle, we were somewhat reassured to allow the hemoptysis to clear preoperatively. Our suspicions were confirmed at surgery and the patient recovered quickly." @default.
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• W2027517323 title "Ventricular Septal Avulsion and Ventricular Septal Defect After Blunt Trauma" @default.
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