J
E Beastall, W A Hadden, S Pandit;
Dept
of Orthopaedic Surgery, Perth Royal Infirmary, Scotland, UK
Correspondence to: James Beastall, 75 Ashgrove Avenue, Aberdeen AB25 3BQ
E-mail: jamesbeastall@hotmail.com
SMJ
2006 51(4): 49
The
purpose of this case is to illustrate an interesting cause of a common symptom.
It is designed to make the reader aware of the possibility of post
traumatic ventricular aneurysm. It
also illustrates the difficulty involved in making an unusual diagnosis in the
Intensive Care setting.
Keywords:
Tachycardia, Ventricular Aneurysm, Traumatic
Ventricular
aneurysm secondary to trauma is exceptionally rare. Accordingly it is a diagnosis that is very infrequently
considered. We describe a case of a
post traumatic aneurysm in a young adult with particular emphasis on the
difficulty encountered in making the diagnosis.
A
17-year-old male was admitted via Accident and Emergency following a high impact
road traffic accident in which he was the front seat passenger of a car.
A tree crushed the passenger side of the car and the injuries he
sustained were compression type injuries.
He
sustained a closed fracture of his left femoral shaft and neck, and open
fractures of both his right femur and humerus.
On his first night post accident a splenectomy was performed at
laparotomy for unresponsive hypotension. An
Electrocardiogram (ECG) showed inferior ST changes.
The following day his fractures were internally fixed.
Over
the course of the following four weeks, he was treated in an Intensive Care Unit
(ICU) due to Adult Respiratory Distress Syndrome (ARDS). Great trouble was
encountered in weaning him from ventilation.
During his time in ICU he had a persistent tachycardia of around 110bpm
with a harsh systolic murmur. Repeat
echocardiography showed a degree of mitral valve regurgitation but normal cusp
movement.
He
was discharged from ICU 27 days following his injuries with a normal ECG. His tachycardia persisted, as did a systolic murmur.
At
this time serial chest radiographs taken on ICU were reviewed and progressive
and abnormal left heart enlargement was seen.
This prompted the decision to perform gated Magnetic Resonance Imaging
(MRI) of his mediastinum. (Figure 1) In this technique the MRI signal is gated
(synchronised) with the ECG allowing a clear image of the moving heart. This
was performed and demonstrated the presence of left ventricular aneurysm.
He
was transferred to the nearest cardiothoracic centre where a Dacron patch repair
was performed. He was discharged
from hospital 67 days post injury. He returned for removal of his metalwork 5
years later, at which time he had graduated as an engineer and had no
restriction of activities.
Blunt
cardiac trauma is relatively common in the multiple injured patient and is
notoriously difficult to treat. The
most common sequelae of blunt cardiac trauma are myocardial contusion,
infarction and coronary artery disease.1
Ventricular aneurysm although recognised, is rare.2
Several cases of traumatic ventricular aneurysm have been reported with
varying outcomes, many of these at post mortem.1,2,3,6,7
The
main diagnostic clue in this case was the presence of a persistent and
unexplained tachycardia of around 110-120 beats per minute.
The diagnosis could not be made until adequate imaging had been
performed. Serial echocardiography
was essentially unremarkable and ECG changes, which had been present on
admission, had returned to normal, suggesting probable contusion.
It was not until MRI imaging was performed that a definite diagnosis was
made.
Persistent
tachycardia has never previously been described as being the predominant
clinical sign of underlying ventricular aneurysm.
This case outlines the need to be aware that ventricular aneurysms can be
present despite normal echocardiography, normal ECG and normal coronary
angiography5,6, and though potentially fatal due to cardiac rupture
or arrhythmia, excellent results can be obtained by surgical repair.
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