Full text of DOI:10.1177/021849230100900218

ÖCAzdSoEg˘SaTnUDY
POSTTRAUMATIC LEFT VENTRICULAR PSEUDOANEURYSM IN A CHILD
POSTTRAUMATIC LEFT
VENTRICULAR
PSEUDOANEURYSM IN A CHILD
M Emin Özdog˘an, MD, G Levent Oktar, MD2,
Sedef Tunaog˘lu, MD1, Mustafa Büyükates¸, MD,
Serdar Kula, MD1, Rana Olguntürk, MD1
Department of Thoracic and Cardiovascular Surgery
1Department of Pediatric Cardiology
Faculty of Medicine
Gazi University
Besevler, Ankara, Turkey
2Department of Cardiovascular Surgery
Dr. Muhittin Ülker Emergency Aid and
Traumatology Hospital
Balgat, Ankara, Turkey
ABSTRACT
A 7-year-old boy developed a left ventricular pseudoaneurysm after being struck
by a tractor. The pseudoaneurysm was diagnosed and successfully resected 5 years
after the accident.
(Asian Cardiovasc Thorac Ann 2001;9:135–7)
cardiography showed a wide dyskinetic segment of the
INTRODUCTION
left ventricle. The patient was referred to our hospital for
further investigation. On admission, he was in sinus rhythm
of 88 beats per minute. His blood pressure was 120/80
mm Hg. His cardiologic examination was normal except
for a mild apical systolic murmur. Echocardiography in
apical 4-chamber view revealed an intact ventricular
septum and left ventriculomegaly. A slightly anterior
angulation of the parasternal long-axis view showed an
interventricular septal aneurysm of 6.2 × 3.8 cm. Left
ventricular dimensions were 5.9 × 2.9 cm (Figure 1). At
cardiac catheterization, pulmonary artery and systemic
arterial pressures were 31/22 and 117/60 mm Hg,
respectively. Cineangiocardiograms demonstrated a small
right ventricular cavity and the calcified wall of an
aneurysm in the diaphragmatic region of the right atrium
Nonpenetrating chest trauma may cause a wide spectrum
of cardiac injury ranging from myocardial contusion to
coronary artery fistula to a cardiac chamber, intra-
ventricular septal or cardiac valve tears, and rupture of
the heart.1,2 The most important cause of cardiac trauma
in peacetime is traffic accidents. Damage to the heart is
not usually foremost in the minds of physicians dealing
with acutely injured persons, and the manifestations of
cardiac trauma can be easily overlooked when other more
obvious injuries are present. In some cases, the patients’
complaints may develop after a long period.
CASE REPORT
A previously healthy 7-year-old boy was struck by a
tractor and received a heavy blunt blow to the sternum.
He experienced only central chest pain and because (Figure 2). Radiopaque solution injected into the left
physical examination and chest radiography were normal ventricle filled a large chamber in the left anterior part of
and his pain eased in a few days, no further investigation the heart, and the interventricular septum was displaced
was planned. When he was 12 years old, he was to a horizontal position. The coronary arteries were normal.
hospitalized with a respiratory infection. His physician
diagnosed mild congestive heart failure, and echo-
Based on these findings, a large interventricular septal
aneurysm extending from the left ventricle was diagnosed.
For reprint information contact:
G Levent Oktar, MD Tel: 90 312 215 5222 Fax: 90 312 310 4242 email: leventoktar@isnet.net.tr
10 Cadde Tusso Bloklari, L-2 Blok Daire: 4, Emek, Balgat, Ankara 06510, Turkey.
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POSTTRAUMATIC LEFT VENTRICULAR PSEUDOANEURYSM IN A CHILD
Özdog˘an
Surgical repair was performed under cardiopulmonary
bypass with aortic crossclamping and cold crystalloid
cardioplegia. A large yellow-white partially calcified
pseudoaneurysm was found arising from the left ventricle
and extending into the right ventricle. The inferior wall
of the pseudoaneurysm was adherent to the diaphragm.
After dissection of the fibrinous adhesions, ventriculotomy
was performed in the region of the pseudoaneurysm.
Aneurysmectomy was carried out as far as possible into
the intact part of the left ventricle. The ventriculotomy
incision was closed with two Teflon strips by linear
suturing. The heart was de-aired through the ventricular
wall before completing closure. After defibrillating the
heart, cardiopulmonary bypass was terminated unevent-
fully. The postoperative period was smooth and the patient
was discharged on the 8th postoperative day. Echo-
cardiography revealed a significant improvement in left
Figure 1. Preoperative echocardiographic view of the pseudoaneurysm.
ANEU = pseudoaneurysm, LA = left atrium, LV = left ventricle,
MV = mitral value, VW = ventricular wall.
ventricular function one month after the operation; the
interventricular septum was intact and the left ventricle
was smaller, measuring 5.4 × 2.6 cm (Figure 3). Table 1
shows the preoperative and postoperative echocardio-
graphic data. At the 3-year follow-up, the operation
appeared to have improved the patient’s prognosis.
DISCUSSION
Cardiothoracic trauma occurs in approximately 30% of
all traumatized patients, mostly due to traffic accidents.3
When the heart is compressed between two objects such
as the sternum and the vertebral column, or when there
is sudden deceleration of the chest with the heart thrust
forward against the sternum, intracardiac, and particularly
intraventricular pressure, suddenly increases and the free
cardiac wall, ventricular septum, the tensor apparatus of
the atrioventricular valves, or the cusps of the aortic valve
may rupture. Less violent blunt trauma may result simply
in contusion of the myocardium. Such a contusion may
vary from a small area of subepicardial or subendocardial
petechia to the full thickness of the cardiac wall.4 Rarely,
a pseudoaneurysm develops after acute rupture of an
infarcted area of the left ventricle.Acquired left ventricular
pseudoaneurysms develop after transmural myocardial
infarction (55%), surgery (33%), trauma (7%), or infection
(5%).5,6 Traumatic pseudoaneurysms are rare, especially
in children. Unlike true aneurysms that have a resistant
wall, pseudoaneurysms initially consist of loose tissues
and have an excessively high propensity for secondary
rupture.7 Such ruptures are usually fatal, but when the
pericardium is sufficiently adherent to the epicardium,
only localized hemopericardium may result. Rupture can
be diagnosed on the basis of pericardial pain or effusion
or by recognition of a pseudoaneurysm on a 2-dimensional
echocardiogram. Although the parietal pericardium may
prevent the expanding pseudoaneurysm from rupturing,
with time it may rupture, usually into the left pleural
cavity.
Figure 2. Right ventricular cineangiocardiogram. ANEU = pseudo-
aneurysm.
In some cases, a left ventricular pseudoaneurysm may
occur due to myocardial infarction after blunt chest
Figure 3. Postoperative echocardiogram. LA = left atrium, LV = left
ventricle, MV = mitral value, RA = right atrium, TV = tricuspid valve.
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Özdog˘an
POSTTRAUMATIC LEFT VENTRICULAR PSEUDOANEURYSM IN A CHILD
a marked improvement in his exercise tolerance after the
operation.
Table 1. Preoperative and Postoperative
Echocardiographic Data
Data
Preoperative
Postoperative
This case is of interest because in spite of the development
LV end-diastolic diameter (mm)
LV end-systolic diameter (mm)
Ejection fraction (%)
59
54
of a large left ventricular pseudoaneurysm, the patient
was diagnosed to have a serious cardiac disorder during
routine physical examination 5 years after blunt chest
trauma. Electrocardiography and echocardiography are
46
40
43.09
21.60
59.03
Fractional shortening (%)
31.07
valuable screening tools for the evaluation of potential
cardiac involvement following nonpenetrating trauma to
the chest.
LV = left ventricular.
trauma.8 Since the patient’s electrocardiograms did not
indicate chronic myocardial infarction, we believe that
the blunt chest trauma directly caused an acute rupture of
the left ventricle and a pseudoaneurysm developed at the
site. Because the rupture was tamponaded by the
diaphragm, hypovolemia and pericardial tamponade did
not occur. The hematoma became organized and
encapsulated in the course of time.
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