Late Discovery of a Traumatic Cardiac Injury A Case Report

Introduction

Penetrating cardiac injuries are rare and often fatal due to significant hemorrhage leading to cardiac tamponade. However, in some cases, these injuries go unnoticed and are diagnosed later through complications. This case study highlights a neglected cardiac injury discovered 45 days after the initial trauma in a young patient presenting with signs of heart failure.

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Case Report

A 25-year-old male was admitted to the emergency department with class III dyspnea. His medical history included an epigastric penetrating wound caused by a 3 cm knife 45 days earlier. Initial radiological examination after the trauma revealed abdominal effusion, leading to exploratory laparotomy, which found no underlying lesions.

Clinical Findings:

• Orthopnea and polypnea (32 cycles/min)
• Tachycardia (120 bpm)
• Blood pressure: 120/80 mmHg
• Jugular venous pulse with giant V waves
• Lower limb edema and hepatomegaly
• Systolic murmur at the apex
• Bilateral pulmonary crackles with fluid effusion

Diagnostic Imaging & Laboratory Tests:

• Chest X-ray: Bilateral effusion, flaky opacities, cardiomegaly
• Electrocardiogram: Regular sinus rhythm
• Blood tests: Anemia (Hb 10.5 g/dL), leukocytosis (11,800/mm3), elevated CRP (77.9 mg/L)
• Transthoracic echocardiography (TTE): Pericardial effusion, right atrial compression, mitral valve defect, high filling pressures, ventricular septal defect (VSD)

Surgical Intervention

Surgery was performed within 48 hours of diagnosis. Upon sternotomy and pericardial opening, thickened pericardium with false membranes was observed, but no active bleeding point was found. The mitral valve was accessed through a trans-septal approach, revealing a 2 cm perforation in the anterior mitral valve.

Surgical Procedures:

• Mitral valve repair via continuous sutures
• Posterior mitral ring reduction with suture annuloplasty
• VSD closure using two interrupted pledgeted prolene sutures

The postoperative course was uneventful, and TTE confirmed a competent mitral valve with no residual shunt. The patient remained asymptomatic during a six-month follow-up period.

Discussion

Penetrating cardiac injuries have high mortality rates, with up to 94% of cases resulting in pre-hospital death. Among those who reach the hospital, 50% succumb despite intensive care. Predictors of survival include signs of life upon emergency room arrival.

Commonly, such injuries involve the ventricles, with the right ventricle being the most frequently affected due to its anterior positioning. The presence of cardiac tamponade typically necessitates immediate surgical intervention. However, in this case, the absence of tamponade delayed diagnosis, making it an exceptional case.

Key Takeaways:

• Penetrating cardiac injuries should be suspected even in the absence of tamponade.
• Epigastric wounds with an unclear trajectory may have cardiac involvement.
• Early and thorough imaging is crucial for accurate diagnosis and timely intervention.

Related Medical Perspectives

The American College of Cardiology (ACC) emphasizes the importance of early echocardiographic assessment in trauma patients to detect cardiac injuries promptly and avoid life-threatening complications.

Read More

For the full study, access the original case report at https://doi.com/10.29328/journal.jccm.1001048.

Explore additional cardiology case studies at https://www.cardiologymedjournal.com/jccm.

Conclusion

This case underscores the importance of maintaining a high index of suspicion for cardiac injuries following penetrating trauma, even in the absence of immediate clinical signs. Proper imaging and prompt surgical intervention can lead to favorable outcomes in seemingly delayed diagnoses.

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