alexa
Reach Us +1-504-608-2390
Unusual Cardiac Gunshot Injury Causing Traumatic Ventricular Septal Defect | OMICS International
ISSN: 2155-9880
Journal of Clinical & Experimental Cardiology

Like us on:

Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Unusual Cardiac Gunshot Injury Causing Traumatic Ventricular Septal Defect

Ram N Bishnoi* and Richard E Ringel
Department of Pediatric Cardiology, Johns Hopkins School of Medicine, USA
Corresponding Author : Ram N. Bishnoi
Department of Pediatric Cardiology
Johns Hopkins School of Medicine
1800 Orleans Street, Bloomberg Children’s Center M2303
Baltimore, MD 21287, USA
Tel: 267-275-4560
Fax: 410-955- 0897
E-mail: [email protected]
Received September 10, 2013; Accepted October 04, 2013; Published October 07, 2013
Citation: Bishnoi RN, Ringel RE (2013) Unusual Cardiac Gunshot Injury Causing Traumatic Ventricular Septal Defect. J Clin Exp Cardiolog 4:271. doi:10.4172/2155-9880.1000271
Copyright: © 2013 Bishnoi RN, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Related article at
DownloadPubmed DownloadScholar Google

Visit for more related articles at Journal of Clinical & Experimental Cardiology

Abstract

Cardiac gunshot injuries are frequently fatal with poor outcome. We report the very unusual survival from cardiac gunshot injuries at multiple sites including the left atrium, left ventricle, right ventricle apex, right ventricular outflow tract and the inter-ventricular septum, creating a large muscular ventricular septal defect (VSD). It shows how rapid transport, proper resuscitation and emergent surgery can improve survival in patients who sustain life threatening cardiac gunshot injuries.

Keywords
Gunshot injury; Ventricular septal defect (VSD); Traumatic cardiac injuries
Introduction
Cardiac injuries can be classified as penetrating and non-penetrating (blunt). Penetrating wounds are usually caused by bullets, missiles or stabbing with a piercing object. The right heart (right atrium or ventricle) is damaged in most cases, because of its anatomical position; making up most of the anterior aspect of the heart. Cardiac trauma from a penetrating chest injury can produce massive hemorrhage, cardiac tamponade, damage to myocardial free wall or inter-ventricular septum, laceration of coronary arteries or great vessels, and serious damage to the conduction system [1,2]. Prognosis and outcome is often not good in cardiac gunshot injuries [3,4].
Case Report
A 19-year-old African American male presented to an outside hospital after experiencing a gunshot injury to the anterior chest at a gas station. His mother put him in the car, and an ambulance took over on the way to the hospital. There was a small entrance wound in the anterior chest with no exit wound. The patient was intubated in route. When he got to the trauma bay in the emergency room, there was pulseless electrical activity. An emergency left thoracotomy was performed by trauma surgery. The pericardium was incised and pericardial tamponade was relieved. Intracardiac cardiopulmonary resuscitation was started. The patient went into ventricular fibrillation and was shocked several times returning to normal sinus rhythm. The estimated blood loss was 2.5 liters. He was taken to the operating room, where the trauma surgeon extended the prior left anterolateral thoracotomy across the midline in a clamshell fashion. There was a 1-cm laceration to the left atrium which was closed. There was another defect closed; 1-cm hole in the apex of the left ventricle. The cardiothoracic surgeon was consulted emergently to facilitate the mediastinal exploration. An injury to the right ventricle anteriorly overlying the right ventricular outflow tract was suture-repaired. There was another injury, which was noted in the apex posteriorly, between the right and left ventricles overlying the septum that was suture-repaired. The bullet was noted to be in the mediastinal sac and was removed. The patient developed acidosis and coagulopathy during the operation requiring massive blood transfusion and fluid resuscitation.
The patient had a prolonged postoperative course. On post-operative day 4, a holosystolic murmur was noted. An echocardiogram showed a 6 to10 mm size anterior mid-muscular ventricular septal defect, but no therapy recommended. He was transferred to a rehabilitation center, where he made huge improvement, being discharged from there with only short-term memory loss.
The patient was recently referred to our cardiology clinic for 1 year follow-up and consideration of transcatheter ventricular septal defect closure. He reported doing well, almost back to his baseline status, apart from getting tired easily probably related to deconditioning and having some short-term memory loss mainly with multi-tasking. The patient was not taking any medications. His physical exam was significant for a pronounced precordial systolic thrill, and a loud, harsh 5/6 holosystolic murmur best heard at the left lower sternal border. There was no clinical evidence of heart failure. An electrocardiogram was repeated and demonstrated rightward axis and qr’ pattern in V1. Echocardiography during the clinic visit showed (Figure 1-3), a moderate (6-10 mm) muscular ventricular septal defect in the anterior portion of the mid to apical septum with low velocity flow across the septum into the right ventricular apex, then high velocity systolic egress from the right ventricular apical trabeculations toward the tricuspid valve via 2 jets with peak instantaneous pressure gradient of 70 mm Hg (Simultaneous systemic systolic blood pressure 113 mmHg). The study also showed normal left ventricular size and function. A cardiac catheterization was performed prior to our office visit, and showed a pulmonary to systemic blood flow ratio (Qp/Qs) of 1.2:1 with high normal systolic right ventricular and pulmonary arterial pressures (28 mm Hg). Thus, our patient’s echocardiography and catheterization findings were consistent with a moderate to large, ventricular septal defect with only minimally elevated right ventricular and pulmonary arterial pressure and minimal left to right shunt. The explanation for this apparent clinical contradiction is that the left to right shunt was restricted by large right ventricular apical trabeculations and brought together by sutures placed blindly in the right ventricular apex during his emergent surgical salvage at the time of presentation. This has produced a situation where the apex of the right ventricle communicates freely with the left ventricle, but only minimally to the right ventricle body and pulmonary bed. Thus, his ventricular septal defect, although large in size, is not hemodynamically significant. Thus, neither percutaneous nor surgical closure was recommended.
Discussion
Penetrating cardiac injuries are life threatening emergencies for which the prognosis depends mostly on the prompt transport, efficient resuscitation, and early surgical intervention, as well as the site and the extent of the injury [1]. Injuries to the heart can result in intracardiac injury at various sites: the right ventricle, right atrium, followed by the left ventricle, left atrium and intrapericardial great vessels.
The mechanisms by which a ventricular septal defect can develop after trauma include acute laceration of the septum, deceleration injury that causes myocardial infarction from an intimal coronary artery tear, and cardiac contusion due to compression of the heart between the sternum and the spine [2,5-7]. The contused myocardium can become necrotic and subsequently become perforated and form a ventricular septal defect. A ventricular septal defect, particularly one caused by blunt trauma, can develop or be detected at any time from hours to months after the original insult. In our patient, we believe that the bullet traveled through the interventricular septum and caused the left ventricle, right ventricle and left atrial lacerations by ricochet effect.
Patients with small traumatic ventricular septal defects with restrictive physiology can be managed conservatively with regular follow-up and serial echocardiography. Small traumatic ventricular septal defects can remain hemodynamically stable for years and even close spontaneously over time [2-4]. Large traumatic ventricular septal defects with a pulmonary to systemic blood flow ratio (Qp/Qs) >2:1 should be closed to prevent congestive heart failure and pulmonary hypertension. The timing of surgical or transcatheter intervention depends upon the patient‘s hemodynamic status. If the patient is hemodynamically stable, closure can be delayed to allow the heart to recover from the contusion and develop fibrosis around the defect, enabling more secure patch or transcatheter occluder placement.
Conclusions
Survivals of gunshot cardiac injuries are uncommon. Early transport, proper resuscitation and emergent surgery can improve survival in patients who sustain such life threatening injuries. The possibility of a traumatic ventricular septal defect should be considered in all trauma patients who develop a new murmur. The need for surgical or transcatheter device closure depends on the physiologic significance of the intra-cardiac shunt.
Acknowledgements
Financial support: This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
References







Figures at a glance

Figure Figure Figure
Figure 1 Figure 2 Figure 3
Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

Article Usage

  • Total views: 11958
  • [From(publication date):
    October-2013 - Nov 18, 2018]
  • Breakdown by view type
  • HTML page views : 8192
  • PDF downloads : 3766
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2018-19
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri and Aquaculture Journals

Dr. Krish

[email protected]

+1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2018 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version