Alteraciones electrofisiológicas y/o bioquímicas del trauma cardíaco / Electrophysiological and/or biochemical alterations of cardiac trauma

Resumen El trauma cardíaco constituye una de las primeras causas de mortalidad en la población general. La gran mayoría son causados por accidentes automovilísticos. Su diagnóstico es difícil y requiere alto índice de sospecha en trauma cerrado. Posee un índice de mortalidad muy elevado, cercano al 76%. Existen varios métodos diagnósticos disponibles para facilitar su detección pero ninguno logra alcanzar una sensibilidad cercana al 100%. El trauma cardíaco contuso puede variar desde lesión cardíaca asintomática hasta ruptura cardíaca y muerte. Actualmente se utilizan marcadores bioquímicos como enzimas cardíacas, siendo la Troponina I la más específica; y electrofisiológicos como hallazgos en el electrocardiograma sugestivos de bloqueo de rama y taquicardia sinusal, siendo estos los más frecuentemente encontrados.

Abstract Heart trauma is one of the leading causes of mortality in the general population. The vast majority are caused by automobile accidents. Its diagnosis is difficult and requires a high index of suspicion in closed trauma. It has a very high mortality rate, close to 76%. There are several diagnostic methods available to facilitate its detection, but none can reach a sensitivity close to 100%. Contusive heart trauma can range from asymptomatic cardiac injury to cardiac rupture and death. Currently, biochemical markers are used as cardiac enzymes, with Troponin I being the most specific; and electrophysiological findings in the electrocardiogram suggestive of branch block and sinus tachycardia, these being the most frequently found.

A risk score model for predicting cardiac rupture after acute myocardial infarction / 中华医学杂志(英文版)

BACKGROUND@#Cardiac rupture (CR) is a major lethal complication of acute myocardial infarction (AMI). However, no valid risk score model was found to predict CR after AMI in previous researches. This study aimed to establish a simple model to assess risk of CR after AMI, which could be easily used in a clinical environment.@*METHODS@#This was a retrospective case-control study that included 53 consecutive patients with CR after AMI during a period from January 1, 2010 to December 31, 2017. The controls included 524 patients who were selected randomly from 7932 AMI patients without CR at a 1:10 ratio. Risk factors for CR were identified using univariate analysis and multivariate logistic regression. Risk score model was developed based on multiple regression coefficients. Performance of risk model was evaluated using receiver-operating characteristic (ROC) curves and internal validity was explored using bootstrap analysis.@*RESULTS@#Among all 7985 AMI patients, 53 (0.67%) had CR (free wall rupture, n = 39; ventricular septal rupture, n = 14). Hospital mortalities were 92.5% and 4.01% in patients with and without CR (P < 0.001). Independent variables associated with CR included: older age, female gender, higher heart rate at admission, body mass index (BMI) <25 kg/m, lower left ventricular ejection fraction (LVEF) and no primary percutaneous coronary intervention (pPCI) treatment. In ROC analysis, our CR risk assess model demonstrated a very good discriminate power (area under the curve [AUC] = 0.895, 95% confidence interval: 0.845-0.944, optimism-corrected AUC = 0.821, P < 0.001).@*CONCLUSION@#This study developed a novel risk score model to help predict CR after AMI, which had high accuracy and was very simple to use.

A case of left ventricle rupture complicating lay rescuer cardiopulmonary resuscitation

Chest compression is the most important component of cardiopulmonary resuscitation, but excessive chest compression can cause serious mechanical complications. Skeletal injuries are the most frequent complications of chest compression, but lacerations of the heart and great vessels are very rare. We report a case of a 62-year-old woman who developed an acute alteration in mental status, and underwent chest compression by a lay rescuer for 5 minutes. When she arrived at the emergency department, she regained consciousness, but constantly complained of chest pain and hypotension. Chest computed tomography revealed a left ventricular free wall rupture with extravasation and hemopericardium. She was managed with surgical repair and was discharged without complications after 21 days of admission.

Morphological analysis of cardiac rupture due to blunt injury, cardiopulmonary resuscitation and myocardial infarction in forensic pathology / 南方医科大学学报

OBJECTIVE@#To analyze the morphological features and forensic pathological characteristics of cardiac ruptures of different causes for their differential diagnosis.@*METHODS@#We analyzed the data of 44 autopsy cases of cardiac rupture from 2014 to 2017 in our institute, including 11 cases caused by blunt violence with intact pericardium, 4 caused by cardiopulmonary resuscitation (CPR), 9 by myocardial infarction, and 20 by aorta dissection rupture.The gross features and histopathological characteristics of cardiac rupture and pericardial effusion were analyzed and compared.@*RESULTS@#Cardiac ruptures caused by blunt violence varied in both morphology and locations, and multiple ruptures could be found, often accompanied with rib or sternum fractures; the volume of pericardial effusion was variable in a wide range; microscopically, hemorrhage and contraction band necrosis could be observed in the cardiac tissue surrounding the rupture.Cardiac ruptures caused by CPR occurred typically near the apex of the right ventricular anterior wall, and the laceration was often parallel to the interventricular septum with frequent rib and sternum fractures; the volume of pericardial blood was small without blood clots; microscopic examination only revealed a few hemorrhages around the ruptured cardiac muscular fibers.Cardiac ruptures due to myocardial infarction caused massive pericardial blood with blood clots, and the blood volume was significantly greater than that found in cases of CPR-induced cardiac rupture ( < 0.05);lacerations were confined in the left ventricular anterior wall, and the microscopic findings included myocardial necrosis, inflammatory cell infiltration, and mural thrombus.Cardiac tamponade resulting from aorta dissection rupture was featured by massive pericardial blood with blood clots, and the blood volume was much greater than that in cases of cardiac ruptures caused by blunt violence, myocardial infarction and CPR ( < 0.05).@*CONCLUSIONS@#Hemorrhage, inflammatory cell infiltration, and lateral thrombi around the cardiac rupture, along with pericardial blood clots, are all evidences of antemortem injuries.

A Case of Ventricular Septal Rupture in Stress Cardiomyopathy

Stress cardiomyopathy (SCMP) is a reversible heart disease, commonly accompanied by emotional or physical stress. Early clinical features are similar to those of acute myocardial infarction, such as acute chest symptoms, ST-segment elevation on electrocardiography, and cardiac biomarkers elevation. However, there is usually no evidence of significant coronary obstruction on a coronary angiogram. Moreover, ventricular dysfunction with regional wall motion abnormalities does not correlate with a single vascular territory. The typical type of SCMP is apical wall motion abnormality with an apical ballooning pattern, and various types of SCMP have recently been reported. Generally, cardiac dysfunction or abnormal wall motion is improved within several weeks, and the prognosis of SCMP is generally good. Thus, the mainstay of the treatment is largely conservative. However, there are some serious complications during the acute phase. In particular, cardiac rupture is a rare but serious structural complication associated with high mortality. In this manner, SCMP could potentially be life threatening during the acute phase, despite it generally being a benign disease in most cases. Early recognition of this complication, appropriate medical therapy, and surgical intervention are required to improve recovery and survival. Here, I report a case of an 83-year-old female patient with SCMP complicated by ventricular septal rupture.

Disrupción auriculoventricular posterior a reoperación de reemplazo valvular mitral: reparación y evaluación ecocardiográfica / Atrioventricular disruption posterior to reoperation of mitral valve replacement: repair and echocardiographic evaluation

La disrupción auriculoventricular después del reemplazo valvular mitral es una rara pero letal complicación. Este caso es el de una mujer de 72 años de edad, con antecedentes de: reemplazo valvular aórtico, mitral, plastia tricúspide y Maze. Se llevó al reemplazo valvular mitral con prótesis Hancock 29 mitral. Se trasladó a la UCI y el curso postoperatorio fue normal hasta las 24 horas después de la cirugía, cuando presentó disnea y requirió soporte inotrópico. Se le realizó un angiotac y un ecocardiograma transtorácico que evidenció pseudoaneurisma ventricular. Fue llevada a cirugía, se inició circulación extracorpórea. Se evidenció disrupción auriculoventricular en el anillo posterior de la válvula mitral (tipo I perforación). La ruptura fue cerrada con un parche mixto de pericardio bovino y dacron con sutura continua. Actualmente, la paciente está en buenas condiciones sin recurrencia. Investigamos: el caso, la etiología, el reparo quirúrgico y la prevención de esta rara complicación y se discute.

Atrioventricular disruption after a mitral valve replacement is a rare but fatal complication. A case of 72 year-old woman is presented. She had a medical history of aortic and mitral valve replacement and Maze and tricuspid valve surgery. Mitral valve replacement was performed with Hancock 29 mitral prosthesis. She was taken to ICU and postoperative progress was normal until 24 hours after the surgery, when she developed dyspnea and required inotropic support. A CT angiography and transthoracic echocardiogram were performed, which evidence a ventricular pseudoaneurysm. She was taken to the operating room to start extracorporeal circulation. Atrioventricular disruption was evidenced in the posterior mitral annulus (type I perforation). Rupture was closed with a using a mixed Dacron and bovine pericardial patch with continuous suture. Patient is currently in good condition with no recurrence. Case, etiology, surgical repair and prevention of this rare complication were investigated and discussed.

Masa en cuello secundaria a electrodo de estimulación cardiaca abandonado / Neck mass secondary to an abandoned pacing lead

Mujer de 70 años de edad, con historia de un electrodo de estimulación cardiaca abandonado, que genera: un trastorno de la deglución y una deformidad estética que la hacen consultar en múltiples oportunidades. A pesar de que se planteó la opción del retiro quirúrgico, se logró una extracción endovascular por la tracción de un electrodo. Describimos la utilidad del eco intracardiaco y el catéter ENSnare®, para la extracción de los electrodos en este tipo de casos.

70-year-old woman with a history of an abandoned pacing lead who developed a deglutition disorder and an aesthetic deformity that made her consult in multiple specialties. Even though surgical removal was considered, endovascular extraction was accomplished with the traction of the lead. We describe the usefulness of the intracardiac echocardiography and the ENSnare® catheter for this type of lead extractions.

Trauma cardiaco cerrado / Blunt cardiac trauma

El trauma cardiaco constituye una de las primeras causas de mortalidad en la población general. Requiere alto índice de sospecha en trauma cerrado severo, mecanismo de desaceleración y en presencia de signos indirectos como: equimosis, huella del volante o del cinturón en el tórax anterior. Las lesiones incluyen: conmoción cardiaca, ruptura cardiaca, lesión cardiaca indirecta como la trombosis coronaria aguda, lesión aórtica, lesión del pericardio y herniación cardiaca. Entre las manifestaciones clínicas están: la angina refractaria a nitratos, el dolor pleurítico, la hipotensión arterial, la taquicardia, la ingurgitación yugular que aumenta con la inspiración, el galope por tercer ruido, el frote pericárdico, los soplos de reciente aparición, los estertores crepitantes por edema pulmonar. El electrocardiograma es el primer eslabón en el algoritmo diagnóstico con hallazgos como: la taquicardia sinusal, los complejos ventriculares prematuros, la fibrilación auricular, el bloqueo de rama derecha y los bloqueos auriculoventriculares. La radiografía de tórax ayuda a descartar lesiones adicionales óseas y pulmonares. La troponina I tiene un valor predictivo negativo del 93% para el trauma cardiaco, otras enzimas como la creatina quinasa total y la creatina quinasa fracción MB son menos específicas. El ecocardiograma está indicado en caso de hipotensión persistente, electrocardiograma con alteraciones o falla cardiaca aguda. El tratamiento incluye la estabilización inicial y un manejo específico de las lesiones. Entre las complicaciones se incluyen: el taponamiento cardiaco, la contusión miocárdica, el síndrome coronario agudo, las arritmias cardíacas y la lesión aórtica. El pronóstico se determina en mayor medida por los signos vitales al ingreso y la presencia de paro cardiaco durante el abordaje inicial.

Cardiac trauma is one of the primary causes of death amongst general population. It requires a high degree of suspicion of severe blunt trauma, deceleration mechanism and presence of indirect signs, such as ecchymosis and steering wheel or seatbelt marks in the anterior chest wall. Injuries include: cardiac concussion, heart rupture, indirect cardiac injury, such as acute coronary thrombosis, aortic injury, pericardial injury and cardiac herniation. The clinical signs and symptoms include: angina refractory to nitrates, pleuritic pain, hypotension, tachycardia, jugular venous distention that increases on inspiration, S3 gallop, pericardial rub, new murmur or crepitant rales due to pulmonary edema. The electrocardiogram is the first link in the diagnostic algorithm leading to findings such as sinus tachycardia, premature ventricular complexes, atrial fibrillation, right bundle branch block and atrioventricular block. Chest X-rays help to rule out other pulmonary or bone injuries. Troponin I has a negative predictive value of 93% for cardiac trauma; other less specific cardiac enzymes are creatine kinase and creatine kinase-MB. Echocardiogram is indicated in presence of persistent hypotension, abnormal ECG results or acute heart failure. The treatment includes initial stabilization and specific management of the injuries. Some complications may include: cardiac tamponade, myocardial contusion, acute coronary syndrome, cardiac arrhythmias and aortic injury. The prognosis of the patient depends on the vital signs at the time of arrival at the emergency department and the presence of cardiac arrest during the initial approach.

Gastric Mucormycosis Followed by Traumatic Cardiac Rupture in an Immunocompetent Patient / 대한소화기학회지

Gastric mucormycosis is a rare and life-threatening fungal disease, caused by fungus in the order Mucorales. While rhino-cerebral and pulmonary forms are common, gastric mucormycosis is an uncommon site for the disease. We diagnosed gastric mucormycosis in a 41-year-old female who had severe multiple trauma, including cardiac rupture, due to a traffic accident. Eighteen days after hospitalization, she passed 800 mL of melena over one day. We performed upper esophagogastroduodenoscopy (EGD) and found a huge gastric ulcer with bleeding. Histopathological examination identified non-septated and right-angled branching fungal hyphae, and we diagnosed gastric mucormycosis. We recommended total gastrectomy to her but she refused the operation, so she was treated with liposomal amphotericin B for 53 days. After two months of treatment with liposomal amphotericin B, we again performed EGD and found a healed gastric ulcer. After four months, with another EGD, we found that the gastric mucormycosis was completely healed.

Blunt Traumatic Cardiac Rupture: Single-Institution Experiences over 14 Years

BACKGROUND: Blunt traumatic cardiac rupture is rare. However, such cardiac ruptures carry a high mortality rate. This study reviews our experience treating blunt traumatic cardiac rupture. METHODS: This retrospective study included 21 patients who experienced blunt traumatic cardiac rupture from 1999 to 2015. Every patient underwent surgery. Several variables were compared between survivors and fatalities. RESULTS: Sixteen of the 21 patients survived, and 5 (24%) died. No instances of intraoperative mortality occurred. The most common cause of injury was a traffic accident (81%). The right atrium was the most common location of injury (43%). Ten of the 21 patients were suspected to have cardiac tamponade. Significant differences were found in preoperative creatine kinase–myocardial band (CK-MB) levels (p=0.042) and platelet counts (p= 0.004) between the survivors and fatalities. The patients who died had higher preoperative Glasgow Coma Scale scores (p=0.007), worse Trauma and Injury Severity Scores (p=0.007), and higher Injury Severity Scores (p=0.004) than those who survived. CONCLUSION: We found that elevated CK-MB levels, a low platelet count, and multi-organ traumatic injury were prognostic factors predicting poor outcomes of blunt cardiac rupture. If a patient with blunt traumatic cardiac rupture has these factors, clinicians should be especially attentive and respond promptly in order to save the patient’s life.

Successful Healing of the Myocardial Rupture Complicated by the Occlusion of a Single Diagonal Branch / 대한내과학회지

Myocardial rupture is a rare but lethal complication of myocardial infarction. Immediate conservative management is critical, but surgery should be considered if the patient's hemodynamic state and degree of hemopericardium do not improve after pericardiocentesis. In this case, a 54-year old patient without underlying disease came to the emergency after experiencing chest pain for two weeks with suddenly aggravated severe dyspnea. The patient was found to have a hemopericardium with cardiac tamponade, so pericardiocentesis was immediately executed. Transthoracic echocardiogram revealed akinesia of the left ventricular muscle and focal wall thinning. The patient was diagnosed with complete occlusion of a single diagonal branch and ventricular free wall rupture using a coronary computed tomography scan. After conservative treatment, vital signs and cardiac function stabilized, and there was no definitive sequela. This case is clinically significant because myocardial rupture, a lethal complication of myocardial infarction, was successfully managed with non-surgical, conservative treatment.

Cardiac Rupture of the Junction of the Right Atrium and Superior Vena Cava in Blunt Thoracic Trauma / 대한중환자의학회지

Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.

Cardiac Rupture of the Junction of the Right Atrium and Superior Vena Cava in Blunt Thoracic Trauma / 대한구급학회지

Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.

Right Ventricular Rupture Caused by Prolonged Cardiopulmonary Resuscitation after Sudden Cardiac Arrest / 대한내과학회지

A 46-year-old male arrived at the emergency department with acute dyspnea. On the way to the hospital, heart massage was performed in the ambulance due to asystole on electrocardiography. After 2 hr of resuscitation, sinus rhythm was restored. Extracorporeal life support and an intra-aortic balloon pump were applied due to cardiogenic shock, but the patient showed sustained hypotension. Echocardiography showed moderate pericardial effusion with physiological evidence of cardiac tamponade; emergency pericardiocentesis was performed, which produced bloody pericardial fluid. An explorative sternotomy revealed a massive hematoma in the mediastinum and right ventricular (RV) free wall rupture. After primary repair, echocardiography showed improved left ventricular systolic function and the patient was stable clinically. This case presents RV free wall rupture as an unusual complication of prolonged heart massage. Heart rupture should be considered in hemodynamically unstable patients after prolonged heart massage.

Ecocardiografía en infarto agudo del miocardio / Echocardiography in acute myocardial infarction

La ecocardiografía es la primera línea de diagnóstico en la fase aguda del infarto agudo del miocardio. Provee información invaluable sobre la estratificación de riesgo, valoración a corto y largo plazo, características hemodinámicas y utilidad en el reconocimiento de la mayoría de complicaciones mecánicas relacionadas con dicho evento. En este artículo se describen algunos parámetros ecocardiográficos que han mostrado evidencia para detectar pacientes en riesgo de pobre pronóstico así como para determinar el tratamiento y las intervenciones de los síndromes coronarios agudos. En conclusión, la ecocardiografía brinda información pronóstica significativa en el manejo de pacientes con infarto agudo del miocardio y debería emplearse en la evaluación rutinaria de este tipo de pacientes.

Echocardiography is the first line of diagnosis in the acute phase of myocardial infarction. It provides invaluable information about risk stratification, assessment of short and long term prognosis, hemodynamic features, and helps to identify the most common mechanical complications related to acute myocardial infaction. In this article, some of the echo cardiographic parameters are decribed that have provided evidence for the detection of those patients at risk of a poor prognosis, and equally important to determine the treatment and interventions in acute coronary syndromes. In conclusion, echocardiography provides strong prognostic information in the management of patients with recent myocardial infarction and should be used always in the routine evaluation of these patients.