Myocardial Contusion Research Articles

Multiple Ventricular Septal Rupture After Blunt Trauma

Ventricular septal rupture occurring as a result of blunt trauma is a very rare clinical condition. Compression of the heart between the sternum and the vertebral column during late diastole or isovolumetric contraction resulting in sudden increase in the intracardiac pressure is a prerequisite for its occurrence. Sudden relief of the inner pressure becomes impossible when the heart is full, thereby resulting in myocardial contusion and rupture. We report a case of a young schoolboy who presented to us with this serious disease and was successfully treated with surgical closure of the defect with a polytetrafluoroethylene patch.

Interpretation of Serum Troponin Elevation

Interpretation of Serum Troponin Elevation

Protective Effect of Previous Cardiac Operation: Survival of Contained Right Ventricular Rupture

Although cardiac contusions are common, cardiac rupture is an uncommon sequela of blunt chest trauma. The mortality rate associated with cardiac rupture is very high, and patients usually do not survive long enough to reach the hospital. We report a 66-year-old man with a history of coronary artery bypass grafting 15 years previously, who was involved in a traffic accident and experienced multiple trauma, including a small contained rupture of the right ventricular outflow tract. He survived, and a false aneurysm developed at the site of the rupture within the next 6 months. The patient then underwent a cardiac operation, and the aneurysm was successfully resected. The intraoperative and postoperative courses were uneventful. In this case, the previous cardiac operation with the resulting pericardial adhesions proved to be lifesaving.

Predictors and Outcome of Early-Onset Pneumonia After Out-of-Hospital Cardiac Arrest

Early-onset pneumonia (EOP) after out-of-hospital cardiac arrest is frequently observed. Causative factors are loss of airway protection during cardiac arrest, pulmonary contusion, and emergency airway management. We assessed the incidence, risk factors, and clinical course of EOP, and evaluated the impact of an early exchange of the prehospitally inserted endotracheal tube (ETT). In our retrospective analysis we included 104 consecutive subjects admitted to our ICU after out-of-hospital cardiac arrest between 2007 and 2012. All subjects underwent therapeutic hypothermia. We analyzed clinical course, inflammation indicators, Clinical Pulmonary Infection Score, occurrence of EOP, duration of ventilatory support, microbiological findings, and short-term outcome. Of the 104 subjects, 46.2% received an exchange of ETT directly after hospital admission. Neither ETT exchange nor observed aspiration were associated with elevated CPIS or EOP, nor with proof of microorganisms in respiratory secretions. We found no differences in duration of ventilatory support, P(aO2)/F(IO2), ICU days, or outcome. C-reactive protein was significantly higher in subjects with aspiration (P = .046). Sex, age, smoking status, aspiration, cause of cardiac arrest, first detected heart rhythm, and use of supraglottic airways devices were not associated with EOP. Subjects with EOP had a longer need for ventilatory support (P = .005), higher tracheotomy rate (P = .03), longer ICU stay (P = .005), higher C-reactive protein (P < .001), higher body temperature (P = .003), higher Clinical Pulmonary Infection Score (P < .001), and lower P(aO2)/F(IO2) (P = .008). The rate of EOP was not significantly influenced by the exchange of the preclinically inserted ETT, but was associated with longer need for mechanical ventilation and ICU stay.

A broken heart: Right ventricular rupture after blunt cardiac injury

A 68 year old woman who was a restrained driver was brought to the hospital after sustaining severe motor vehicle accident. She underwent CT of the chest demonstrating pulmonary infiltrates, multiple rib fractures, bilateral hemo- and pneumothoraces. Subsequent review of the images noted contrast extravasating from the apical portion of the right ventricle into the pericardial space, demonstrating a confined rupture of right ventricle. Cardiac rupture is a common complication of a rare event and there are few examples in the imaging literature capturing such event.

Cardio-embolic stroke following remote blunt chest trauma

A cardio-embolic stroke as a sequela of remote blunt chest trauma is a rare clinical presentation. Blunt chest trauma can cause various acute cardiac complications like arrhythmias, cardiac contusion etc. However, delayed consequences such as left ventricular thrombus resulting in thromboembolic phenomena are reported infrequently.A 30-year-old healthy man presented to an outside facility with transient neurological deficits. An MRI brain showed lesions suggestive of embolic etiology. A trans-thoracic echocardiogram (TTE) showed a 1.5 × 1.5 cm mass present in the left ventricular (LV) apex. Patient was transferred to our institution for cardiac surgery evaluation. On detailed questioning, he reported an incident of blunt chest trauma during a martial arts exhibition fight that took place 2 years back. Given this history, a cardiac catheterization was done, which showed 30% stenosis in mid-left anterior descending artery (LAD) without any other significant obstructive lesion. A trans-esophageal echocardiogram (TEE) showed akinesis of the LV apex and confirmed TTE finding of a mass, consistent with an apical thrombus. Surgery was deferred and patient was started on anticoagulation. A cardiac MRI done 2 weeks later showed evidence of apical infarction in the LAD territory.LAD is the most commonly affected coronary vessel by blunt traumatic injuries, likely due to its vulnerable anatomical position on the anterior aspect of the heart. A variety of mechanisms including intimal tear, rupture and spasm have been implicated in the pathogenesis of myocardial infarction after blunt chest trauma.

Pain-associated Respiratory Failure in Chest Trauma

Pain-associated Respiratory Failure in Chest Trauma

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: A clinical multicentre study

ObjectiveTo report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries. MethodsHistoric cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011. ResultsThe most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years. ConclusionsTraumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis.

Cardiac emergencies: Blunt chest trauma

Blunt chest trauma is considered a major health problem worldwide because of the tremendous increase of the motor vehicle accidents. Any part of the heart or the great vessels can be injured. Hemopericardium and myocardial contusion are the most frequent cardiac lesions in patients who survive a motor vehicle accident. Rupture of a cardiac chamber, the aorta, or the coronary arteries is often fatal. Valve ruptures especially of the tricuspid valve carry a better prognosis. Diagnosis is based on troponin and cardiac enzymes measurement, ECG changes, chest X-ray, echocardiography and spiral computed tomography. Management of patients with compromised hemodynamics and progressive deterioration is surgical often on an emergent basis.

Traumatic mitral valve and pericardial injury.

Cardiac injury after blunt trauma is common but underreported. Common cardiac trauma after the blunt chest injury (BCI) is cardiac contusion; it is very rare to have cardiac valve injury. The mitral valve injury during chest trauma occurs when extreme pressure is applied at early systole during the isovolumic contraction between the closure of the mitral valve and the opening of the aortic valve. Traumatic mitral valve injury can involve valve leaflet, chordae tendineae, or papillary muscles. For the diagnosis of mitral valve injury, a high index of suspicion is required, as in polytrauma patients, other obvious severe injuries will divert the attention of the treating physician. Clinical picture of patients with mitral valve injury may vary from none to cardiogenic shock. The echocardiogram is the main diagnostic modality of mitral valve injuries. Patient's clinical condition will dictate the timing and type of surgery or medical therapy. We report a case of mitral valve and pericardial injury in a polytrauma patient, successfully treated in our intensive care unit.

Interpretation of Serum Troponin Elevation

Interpretation of Serum Troponin Elevation

Screening for blunt cardiac injury

Diagnosing blunt cardiac injury (BCI) can be difficult. Many patients with mechanism for BCI are admitted to the critical care setting based on associated injuries; however, debate surrounds those patients who are hemodynamically stable and do not otherwise require a higher level of care. To allow safe discharge home or admission to a nonmonitored setting, BCI should be definitively ruled out in those at risk. This Eastern Association for the Surgery of Trauma (EAST) practice management guideline (PMG) updates the original from 1998. English-language citations were queried for BCI from March 1997 through December 2011, using the PubMed Entrez interface. Of 599 articles identified, prospective or retrospective studies examining BCI were selected. Each article was reviewed by two members of the EAST BCI PMG workgroup. Data were collated, and a consensus was obtained for the recommendations. We identified 35 institutional studies evaluating the diagnosis of adult patients with suspected BCI. This PMG has 10 total recommendations, including two Level 2 updates, two upgrades from Level 3 to Level 2, and three new recommendations. Electrocardiogram (ECG) alone is not sufficient to rule out BCI. Based on four studies showing that the addition of troponin I to ECG improved the negative predictive value to 100%, we recommend obtaining an admission ECG and troponin I from all patients in whom BCI is suspected. BCI can be ruled out only if both ECG result and troponin I level are normal, a significant change from the previous guideline. Patients with new ECG changes and/or elevated troponin I should be admitted for monitoring. Echocardiogram is not beneficial as a screening tool for BCI and should be reserved for patients with hypotension and/or arrhythmias. The presence of a sternal fracture alone does not predict BCI. Cardiac computed tomography or magnetic resonance imaging can be used to differentiate acute myocardial infarction from BCI in trauma patients.

Ventricular Septal Avulsion and Ventricular Septal Defect After Blunt Trauma

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.

EComment. Tricuspid valve and blunt chest trauma

We read with interest the article by Thekkudan and associates regarding the tricuspid valve chordal rupture due to blunt injury and we agree with their comment that the timing of the surgical intervention in the heart valve depends on the patient's general clinical condition [1]. Cardiac valvular injuries are quite uncommon after blunt thoracic trauma and the tricuspid valve is perhaps the more vulnerable because of the proximity of the right ventricle to the sternum [2]. Bailey et al. have highlighted that even a moderate blunt chest injury can provoke a significant injury of cardiac valves [2]. The major causes of injury are related to motor vehicle accidents followed by falls from one or more stories, falls off a horse or bus and compressed air explosions [2, 3]. Van Son et al. have reported on their experience with the surgical management of thirteen patients with tricuspid insufficiency due to blunt chest trauma (twelve cases were related to motor vehicle accidents and one to an explosion of a tank of compressed air). The median duration between trauma and surgical treatment was 17 years (range, 1 month to 37 years) and the primary cause of tricuspid insufficiency was flail of the anterior leaflet because of chordae tendinea rupture (n = 9), rupture of anterior papillary muscle (n = 3), or tear in the anterior leaflet (n= 1). In one patient, the septal leaflet was missing and in another it was retracted and adherent to the ventricular septum. Eight patients underwent tricuspid valve replacement and four tricuspid valve repair. No early or late deaths occurred at a median follow-up of 12 years [3]. Choi and Kim have reported on the successful management of simultaneous rupture of mitral and tricuspid valve with left ventricular rupture due to blunt chest injury. Their brief review of the relevant literature found that only eight patients had simultaneous rupture of the atrioventricular valves [4]. The diagnostic and therapeutic approach is a real challenge for these complex cases. When cardiac trauma is suspected after blunt chest trauma, transthoracic echocardiography can facilitate its appropriate management. However, the atrioventricular valve rupture can be missed due to cardiac tamponade and resultant ventricular collapse or due to other significant thoracic injuries [4]. In controversial cases or in extremely unstable patients transesophageal echocardiography (preoperative and/or intraoperative) can establish the definitive diagnosis [2]. Post-traumatic tricuspid and mitral valve repair has to be considered very carefully because these patients are haemodynamically unstable and there are anatomic valvular difficulties such as myocardial contusion, focal endocardial ischaemia, friable endocardium and necrotic papillary muscle. Because the right heart is a low-pressure system and the septomarginal trabecula is thick, the ruptured anterior papillary muscle can be reattached to its primary position with the use of the native chordae or neochordae with pledgeted sutures [1, 4]. In conclusion, the experience of valve repair in blunt chest trauma is limited however, especially for the tricuspid valve this therapeutic modality can be effective.

Complete Heart Block Following a Blow on the Chest by a Soccer Ball: A Rare Manifestation of Commotio Cordis

Commotio cordis is a rare type of blunt cardiac injury in which low impact chest trauma causes sudden cardiac arrest, usually occurs from being struck by a projectile during sports. The most common arrhythmia during commotio cordis is ventricular fibrillation, although complete heart block and an idioventricular rhythm have also been reported. We describe a case of a young patient who presented with a persistent third-degree atrioventricular block and a left bundle branch block, following blunt chest trauma, as a result of blow by soccer ball and subsequently needed a permanent pacemaker.

A modified rat model of isolated bilateral pulmonary contusion

The aim of the present study was to create a feasible specific rat model of isolated bilateral pulmonary contusion (PC) and to evaluate the relationship between severity of hypoxemia and quantity of contusion lesions. Anesthetized rats were placed in a prone position. Injury energy ranging from 2.1 to 3.0 J was produced by a falling weight passed through a specially designed arched shield to the bilateral chest wall of rats. After injury (4 h), the contusion volume was measured using computer-generated three-dimensional reconstruction from a chest computed tomographic scan and expressed as a percentage of total lung volume. Arterial partial pressure of oxygen (PaO2) in blood gas analysis and contusion volume percentage were used to assess the severity of contusion. Heart and lung biopsy was used to confirm the diagnosis and rule out the existence of myocardial contusion. There were 3 cases of death and 1 case of death in the 3.0 J and the 2.4 J group, respectively. PaO2 in the 2.7 J group was significantly lower than that in the lower energy groups (P<0.001). The percentage of pulmonary contusion in the 2.7 J group was significantly higher compared to that of the lower energy groups (P<0.001). PaO2 was negatively correlated with contusion percentage (R2=0.76). Hemorrhage, edema and neutrophil infiltration were determined by lung biopsy. No evidence of myocardial contusion was documented in multiple heart biopsies. The method illustrated in this research effectively duplicates isolated bilateral pulmonary contusion in rats, the severity of which is highly correlated with the contusion size. Thus, 2.7 J can be regarded as the maximal energy for sublethal injury.

Mechanism of safflor injection treating myocardial contusion after chest impact

Objective To investigate the mecbanism of safflor injection treating myocardial contusion following thoracic impact.Methods Thirty healthy Japan big-ear rabbits were randomly assigned to the myocardial contusion control group (control group,n =15) and safflor injection group (safflor group,n =15).The rabbits with severe myocardial contusion were induced by BIM-Ⅱ Horizontal Bioimpact Machine.Blood samples were taken from common carotid artery of both groups to measure the levels of plasma thromboxance A2 (TXA2) and prostaglandin I2 ( PGI2 ) at 10 minutes before impact and at t0 minutes,30 minutes,1,3,6,12 and 24 hours after impact.Rabbits were dissected to observe the gross and micropathological changes of the hern at 24 hours after impact.Results The control group showed a distinct falling of plasma PGI2 concentration and a significant increase of plasma TXA2 concentration in the early period after severe myocardial contusion.The morphological observation revealed severe myocardial tissue injury as well.However,the safflor group showed insignificant variation pertaining to the reduction of plasma PGI2 concentration and increase of plasma TXA2 concentration,but obvious alleviation of myocardial tissue injury,as compared with the control group.Meanwhile,the ratio of TXB2 to 6- Ketoprostaglandin Fla (6-Keto-PGFla) in the safflor group was lower than that of the control group (P ＜0.05).Conclusion Safflor injection has therapeutic effect on myocardial contusion by elevating the concentration of plasma PGI2 and decreasing the concentration of plasma TXA2 in the early period after severe myocardial contusion. Key words: Thoracic injuries; Myocardium; Safflor injection

Tricuspid valve chordal rupture due to airbag injury and review of pathophysiological mechanisms

Blunt trauma to the chest is associated with significant morbidity and mortality. The latter is usually due to an aortic transection, whereas the former is related to myocardial contusion, cardiac valve injury, coronary artery disruption and intracardiac shunts due to the formation of septal defects. The main mechanisms causing these injuries are due to the sudden deceleration force and compression within the chest cavity. Moreover, there is also the sudden increase in intravascular pressure due to a mechanical compression effect and a hormonal adrenergic surge during the event. We report a case of a tricuspid valve injury caused by the deployment of the airbag during a high-speed impact car accident and the subsequent damage to the tricuspid valve chordal mechanism. The patient's management and the pathophysiological mechanisms involved in the injury are reviewed.

Cardiac tamponade: contrast reflux as an indicator of cardiac chamber equalization

BackgroundTraumatic hemopericardium remains a rare entity; it does however commonly cause cardiac tamponade which remains a major cause of death in traumatic blunt cardiac injury.ObjectivesWe present a case of blunt chest trauma complicated by cardiac tamponade causing cardiac chamber equalization revealed by reflux of contrast.Case reportA 29-year-old unidentified male suffered blunt chest trauma in a motor vehicle collision. Computed tomography (CT) demonstrated a periaortic hematoma and hemopericardium. Significant contrast reflux was seen in the inferior vena cava and hepatic veins suggesting a change in cardiac chamber pressures. After intensive treatment including cardiac massage this patient expired of cardiac arrest.ConclusionReflux of contrast on CT imaging can be an indicator of traumatic cardiac tamponade.

Imaging Patients with Cardiac Trauma

In the United States, trauma is the leading cause of death among those who are 1-44 years old, with cardiovascular injuries representing the second most common cause of traumatic death after central nervous system injuries. Evaluation of trauma patients with suspected cardiac injury may be complex and include electrocardiography, measurement of cardiac biomarkers, and imaging examinations. Contrast material-enhanced computed tomography (CT) has become one of the most valuable imaging tools available for evaluating hemodynamically stable patients with suspected cardiac injury. The presence of hemopericardium, with or without cardiac tamponade, is one of the most significant findings of cardiac injury. Other complications that result from blunt cardiac injury, such as pericardial rupture and cardiac herniation, may be readily depicted at multidetector CT. Assessment of patients with cardiac injuries, particularly those with penetrating injuries, is a challenging and time-critical matter, with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis. Patients who are hemodynamically stable, particularly those with penetrating cardiac injuries, also may benefit from a timely imaging examination. In addition to chest radiography, other available modalities such as transthoracic and transesophageal echocardiography, nuclear medicine, and magnetic resonance imaging may play a role in selected cases.