J Thorac Cardiovasc Surg 2004;127:275-276
© 2004 The American Association for Thoracic Surgery
Ventricular septal defect caused by impact from a horseshoe
Jorge Palazuelos Molinero, MD,
Diego Martín-Raymondi, MD,
Juan Cosín-Sales, MD, PhD,
Gregorio Rábago Juan-Aracil, MD,
José Daniel Sáenz de Buruaga, MD,
Joaquín Barba Cosials, MD, PhD
Clinical summary
A 16-year-old woman came to the emergency department 36 hours after a closed thoracic trauma that had occurred when she was dropped from her horse and then was trodden on by her horse. Acute dyspnea and concomitant hemoptysis were her reasons for seeking treatment. Physical examination showed a pulse of 130 beats/min and blood pressure of 95/45 mm Hg, paleness, and erosions over the skin in the image of a horseshoe. The heart had a normal S1 and S2 sounds and grade 6/6 holosystolic murmur at the left bottom sternal border irradiating to the right bottom sternal border. There was bibasal hypoventilation with a tubaric murmur on the right thorax. Electrocardiography demonstrated elevation of the ST segment in the right leads. Biochemical testing showed a hemoglobin level of 10.3 g/dL, total creatine kinase of 222 IU/L, MB isoenzyme of creatine kinase of 7.8 (index 3.5%), and cardiac troponin I level of 13.10 ng/mL. Chest radiography (Figure 1) showed a normal cardiac size, Kerley B lines, pulmonary congestion, and bilateral pleural effusion. Computed tomographic scan showed multiple rib fractures, pulmonary contusion, and pericardial effusion. These data were compatible with a ventricular septal defect. An echocardiogram was therefore performed (Figure 2). On transthoracic apical 4-chamber view, the ventricles appeared dilated and dysfunctional and demonstrated a ventricular septal defect 1.5 cm in length with a severe left-to-right shunt and wall motion abnormalities.
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Figure 1. Chest radiograph showing normal cardiac size, Kerley B lines up to middle lungs, bilateral pleural effusion with presence of venocapillary congestion, and prominent main pulmonary artery.
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Figure 2. Transthoracic echocardiogram on apical 4-chamber view demonstrated ventricular septal defect 1.5 cm in length with significant left-to-right shunt.
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Inotropic support was started during the wait for surgical correction. Through a right ventricular approach, the ventricular septal defect was seen, with flattening of the flaps. In addition, there was severe dilatation of the right ventricle, with an hypokinetic area and a 3-cm contused region. The ventricular septal defect was closed with a 2-cm polytetrafluoroethylene patch (Figure 3). On echocardiography at discharge, there was no evidence of right or left ventricular dysfunction, and there were no signs of shunt. One year after the operation, the patient is free of symptoms and doing well.
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Figure 3. During surgical repair, ventricular septal defect was closed with 2-cm polytetrafluoroethylene patch.
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