630491

research-article2016
CTO0010.1177/2055552016630491Cardiovascular and Thoracic OpenMonroe et al.

Case Study
CTO
Cardiovascular and Thoracic Open

Blunt cardiac injury without Volume 2: 15

The Author(s) 2016
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DOI: 10.1177/2055552016630491

A report of two pediatric cases cto.sagepub.com

Dustin E Monroe1, Jennifer Willert2, Ziad Saba3,

Howard Rosenfeld3 and Brigham C Willis4,5

Abstract
Objective: To report two cases of cardiac injury following blunt thoracic trauma without external evidence of injury.
Design: Case report and review of the literature.
Setting: A 23-bed pediatric intensive care unit in an academic childrens hospital.
Interventions: Two children presented following significant thoracic trauma without external evidence of injury.
Cardiac injury was not initially suspected, and lack of definitive diagnostic evaluation led to a delay in diagnosis and
definitive treatment.
Results: A 4-year-old girl presented 6months after initial injury and evaluation with massive right ventricular dilatation
secondary to traumatic tricuspid regurgitation. The second patient, an 11-year-old boy, underwent a laparotomy for
suspected abdominal pathology delaying diagnosis of his traumatic ventricular septal defect and definitive repair until
clinical hemodynamic deterioration occurred.
Conclusion: Clinicians should maintain a high index of suspicion for cardiac injury in patients with a significant mechanism
of thoracic trauma despite external evidence. Standard screening tests are often inadequate and echocardiography
should be performed for any suspected cardiac trauma.

Keywords
television, trauma, tricuspid regurgitation, ventricular septal defect

Date received: 17 December 2015; accepted: 12 January 2016

Background
Cardiac injury following blunt chest trauma, while rare,1,2
may be life threatening if not detected expeditiously. It is
commonly associated with obvious external signs of tho- 1Division of Pediatric Critical Care Medicine, Phoenix Childrens
racic injury, with the majority of complications being Hospital, Phoenix, AZ, USA
described within 48h of the event.1,2 We report two pediat- 2Division of Pediatric Hematology/Oncology, Childrens Hospital San

ric cases illustrating cardiac injury without external signs of
thoracic trauma, one of the cases with the cardiac complica-
tion presenting temporally remote to the traumatic event.
Diego, University of CaliforniaSan Diego, San Diego, CA, USA
3Department of Pediatric Cardiology, Childrens Hospital and Research
Center at Oakland, Oakland, CA, USA
4Department of Child Health, College of Medicine, University of

Arizona, Phoenix, AZ, USA

5Division of Cardiovascular Intensive Care, Phoenix Childrens
Case reports Hospital, Phoenix, AZ, USA
Case 1 Corresponding author:
Dustin E Monroe, Division of Pediatric Critical Care Medicine, Phoenix
A 4-year-old girl was admitted to our facility for respiratory Childrens Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA.
distress following 3days of decreased activity, intermittent Email: dmonroe@phoenixchildrens.com

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2 Cardiovascular and Thoracic Open

vomiting, cough, and decreased oral intake. Six months

prior to this visit, the patient was evaluated in a local emer-
gency department for blunt chest and abdominal trauma
suffered during a crush injury from a falling television.
Evaluation at that time included chest X-ray; head, abdo-
men, and pelvis computed tomography (CT) scan; and uri-
nalysis, all of which were normal. Physical examination
was unremarkable, with no external signs of trauma, and
the patient was discharged without scheduled follow-up.
On initial evaluation in our emergency department, a
harsh, III/VI widely radiating regurgitant murmur was appre-
ciated, and chest X-ray revealed marked cardiac enlarge-
ment, suggestive of cardiomyopathy. Echocardiogram
revealed a severely dilated right ventricle with normal left
ventricular size and function. There appeared to be an
unguarded tricuspid valve with free tricuspid insufficiency
secondary to rupture at the valve annulus (Figure 1). The
patient was stabilized in the intensive care unit and taken for
semi-urgent repair on the morning following admission.
Intraoperative findings revealed severe dilatation of both
the right atrium and ventricle, with a fistulous, paravalvar
communication between the tricuspid annulus and the atrio-
ventricular wall, along with a tear from the annulus into the
septal and anterior leaflets. The annulus was reconstructed
and reattached to the atrioventricular groove; the leaflet tear
was repaired and the atrium plicated. An unremarkable
recovery led to discharge on post-operative day 3. On fol-
low-up at 6weeks, she was asymptomatic, with normal tri-
cuspid valve function by transthoracic echocardiogram.
Case 2
An 11-year-old boy sustained blunt trauma to the chest
wall and abdomen from a crush injury while attempting to
lift a heavy park bench. Initial emergency room evaluation
revealed no external evidence of trauma to the chest wall.
The patient was hypotensive with poor peripheral perfu-
sion, had a soft systolic murmur, and exhibited abdominal
tenderness. Cardiac silhouette and pulmonary markings
were normal on chest roentgenogram. Electrocardiogram
(EKG) revealed first-degree atrioventricular block and
right bundle branch block. CT of the chest and abdomen
demonstrated a left-sided pulmonary contusion and free
peritoneal fluid. Cardiac injury was not suspected and
exploratory laparotomy revealed only a small duodenal
hematoma. Post-operatively, the patients hemodynamic
status deteriorated, and emergent echocardiogram demon-
strated a large conoventricular septal defect.
Upon presentation at our institution, chest roentgenogram
showed diffuse pulmonary edema without cardiomegaly and
a left-sided consolidation consistent with pulmonary contu-
sion. Serum creatine kinase (CK) level was elevated at
718U, with a 48% myocardial (MB) fraction. Transesophageal
echocardiogram demonstrated a 1.2cm1.6cm ventricular
septal defect (VSD) caused by avulsion of the membranous
Figure 1. Traumatic rupture of the tricuspid valve. (a)
Echocardiogram revealed a severely dilated right ventricle with
normal left ventricular size and function. (b) There appeared
to be an unguarded tricuspid valve with free tricuspid
insufficiency secondary to rupture at the valve annulus.
septum at its insertion to the aortic annulus (Figure 2). There
was a large left to right shunt restrictive by 30mmHg with
hyperdynamic left ventricular function. There appeared to be
limited support for the noncoronary aortic cusp with partial
prolapse into the septal defect.
Further clinical deterioration led to urgent surgical inter-
vention 48h after presentation. Intraoperative inspection
revealed a 3cm 2cm VSD extending inferiorly from the
membranous septum. In addition, a previously unidentified
transmural (covered only by epicardium) tear of the right
ventricular free wall and partial avulsion of the pulmonary
valve cusp were identified. The VSD was closed with bovine
pericardium, and the right ventricular free wall defect was
sutured primarily. The patients sternum was left open for
48h after operation due to ventricular dysfunction on
attempted primary closure. His hospital course was further
complicated by sinus node dysfunction responsive to pacing.
The patients conduction abnormalities improved after ster-
nal closure, and follow-up EKG was significant only for
right bundle branch block. The patient was discharged home
on the 11th post-operative day, and at 6months of follow-up,
he has resumed normal activity and is asymptomatic.
Institutional review board review was not required for
case reports at our institution at the time of case presenta-
tion and information retrieval.
Discussion
Most commonly, severe cardiac trauma presents acutely
and is associated with evidence of significant chest wall

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Monroe et al. 3
Figure 2. Traumatic ventricular septal defect (VSD).
(a) Transesophageal echocardiogram demonstrated a
1.2cm1.6cm VSD caused by avulsion of the membranous
septum at its insertion to the aortic annulus. (b) There
was a large left to right shunt restrictive by 30mmHg with
hyperdynamic left ventricular function. There appeared to be
limited support for the noncoronary aortic cusp with partial
prolapse into the septal defect.
injury. However, it is possible to suffer serious cardiac
injury from a blunt trauma without obvious external mani-
festations. In one large pediatric series on cardiac trauma
to date, Dowd and Krug1 reported on 184 cases of blunt
cardiac injury in children, with 95% having simple car-
diac contusion and two suffering traumatic VSD; 87.5%
of these patients suffered serious multisystem injury, but
only 60% had external evidence of thoracic trauma.
Pulmonary contusion, presenting clinically or radiograph-
ically, which was seen in our second case, was the most
frequent injury associated with blunt chest trauma and
multiorgan injury is twice as frequent in these patients.1,3
Other case reports of traumatic VSD had associated pul-
monary contusions and has been shown to be a life threat-
ening injury.4,5 The presence of pulmonary contusion
should alert the physician to the possibility of occult car-
diac trauma.
Electrocardiographic abnormalities, common after
pediatric cardiac trauma, appear to correlate well with the
presence of traumatic VSD in the adult population (37/49
cases).6 In one pediatric case of avulsed VSD after motor
vehicle collision, echocardiography reported a mobile
thrombus in the left ventricular outflow tract with evidence
of septal wall abnormality.7 The occurrence of these types
of abnormalities after blunt chest trauma clearly warrants
careful cardiac evaluation.
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Elevation in serum CK MB fraction (CK-MB) is fre-
quently present in the adult population after cardiac injury,
but elevation of CK-MB appears to be a nonspecific find-
ing in cases of pediatric chest trauma. Bromberg etal.8
showed that seven of eight pediatric patients with cardiac
trauma had elevated serum CK-MB, but only one had a
clinically significant injury requiring intervention. Other
serum assays, cardiac troponin I and cardiac troponin T,
which are highly specific markers of myocardial injury,
have sensitivities of only 23% and 12%, respectively, in
evaluating for cardiac injury after blunt chest trauma.9
Given the lack of sensitivity of frequently used screening
tools, our reported cases confirm that two-dimensional
echocardiography, employed as a screening tool, is the
most sensitive and specific modality for diagnosis of car-
diac injury after thoracic trauma.6,10 Cardiac enzymes may
be useful as an adjunct in diagnosis but cannot be relied
upon to rule in or rule out significant cardiac injury.
While post-traumatic tricuspid regurgitation is quite
uncommon, especially in the pediatric population,1114
there is a small but significant literature describing its
presentation well after the inciting event, with two series
reporting mean times to correction of 13 and 17years.15,16
Low pulmonary vascular resistance and right ventricular
pressures can allow significant hemodynamic abnormali-
ties to go unrecognized for months to years. Mild injury
with resultant tricuspid insufficiency can worsen over time
until overt right ventricular dysfunction occurs. The pre-
sumed mechanism of injury to the tricuspid valve is a sud-
den rise in right ventricular pressure due to compression of
the thorax, which can lead to strain and rupture of the ten-
sor apparatus and leaflets.17 In all reported cases, leaflet
dysfunction has been the cause of the valvular dysfunc-
tion, with most having rupture of the anterior chordae
tendinae with ensuing annular dilation.1121 Our patient
was unique in suffering separation of the leafletalong its
border with the tricuspid annulus. While delayed surgical
repair can result in excellent long-term results, current lit-
erature supports early diagnosis and intervention in order
to avoid right ventricular dilation and failure.21
The VSD here reported, located at the membranous sep-
tum, contrasts with the more posterior and apical location
generally reported for the traumatic VSD. The most fre-
quent mechanism for ventricular rupture involves a sudden,
rapid, high-velocity blow to the thorax causing acute rup-
ture of the septum, most commonly at its posterior inser-
tion.22 Our patient suffered a slow, crushing impact to the
chest. We postulate that this crushing impact along with
possible torsional forces led to a tearing of the ventricular
septum from its attachments at the crux of the heart. The
nearly through-and-through tear of the right ventricular
free wall opposite the membranous septum supports this
theory. The possibility of rupture at the level of the mem-
branous septum or extension into the membranous septum
must be considered in the preoperative evaluation of the
4 Cardiovascular and Thoracic Open
patient with suspected ventricular rupture. Similarly, the
presence of associated defects such as right ventricular free
wall rupture and damage to the semilunar valves must be
considered.
Optimal timing for surgical repair in the traumatic VSD
remains undetermined. Some authors recommend delay in
repair in order to allow for stable hemodynamics and
improved tissue integrity at wound edges.22,23 Attempted
early repair in the setting of hemodynamic instability has
been relatively unsuccessful in previously reported pediat-
ric cases,4,5 with right ventricular dysfunction contributing
to poor surgical outcome in at least one patient. In the set-
ting of progressive clinical deterioration, our patient
underwent successful early repair with delayed sternal clo-
sure. It is possible that delayed sternal closure in this case
may have allowed early surgical repair without subsequent
hemodynamic deterioration from right ventricular dys-
function. This hypothesis is supported by recent experi-
ence with delayed sternal closure in other high-risk
pediatric cardiac surgeries.24
Conclusion
A history of significant blunt thoracic trauma should lead
to a high level of suspicion for cardiac injury, with hemo-
dynamic instability, EKG abnormality, arrhythmia, or new
murmur requiring prompt echocardiographic evaluation.
Controversy exists regarding the utility of an echocardio-
gram in the evaluation of the child with thoracic trauma
where the patient appears well with no external injuries but
has a significant mechanism of trauma. The possibility of
silent cardiac injury, as illustrated by these cases, warrants
echocardiography in those patients with a history of sig-
nificant thoracic trauma. While many cases with cardiac
injury can be managed conservatively, detailed transtho-
racic (and when necessary transesophageal) echocardio-
grams are mandated in order to define those cases requiring
intervention. Finally, significant cardiac defects may
develop over time as late sequelae of thoracic trauma and
should be considered by the primary care practitioner dur-
ing long-term follow-up care.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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