Almanac of Clinical MedicineAlmanac of Clinical MedicineАльманах клинической медицины2072-05052587-9294Moscow Regional Research and Clinical Institute (MONIKI)108410.18786/2072-0505-2019-47-038CLINICAL CASESКЛИНИЧЕСКИЕ НАБЛЮДЕНИЯPenetration cardiac wound associated with anterior mitral leaflet perforation: a case report and review of the literatureПроникающее ранение сердца с перфорацией передней створки митрального клапана: клиническое наблюдение и обзор литературыhttps://orcid.org/0000-0002-6105-864XBasarabD. A.БасарабД. А.
Russian Federation

Dmitriy A. Basarab – MD, PhD, Cardiovascular Surgeon, Cardiovascular Department, Chief Cardiovascular Surgeon of the Healthcare Department of the Belgorod Region.

8/9 Nekrasova ul., Belgorod, Belgorod Region, 308009, Tel.: +7 (910) 226 16 76

Басараб Дмитрий Алексеевич – канд. мед. наук, врач сердечно-сосудистый хирург кардиохирургического отделения БОКБ, главный внештатный специалист сердечно-сосудистый хирург Департамента здравоохранения Белгородской области.

308009, Белгородская обл., Белгород, ул. Некрасова, 8/9, Тел.: +7 (910) 226 16 76

basarab.74@yandex.ruhttps://orcid.org/0000-0001-7585-9344UstyuzhinE. D.УстюжинЕ. Д.
Russian Federation

Egor D. Ustyuzhin – MD, Cardiovascular Surgeon, Cardiovascular Department.

8/9 Nekrasova ul., Belgorod, Belgorod Region, 308009 

Устюжин Егор Дмитриевич – врач сердечно-сосудистый хирург кардиохирургического отделения.

308009, Белгородская обл., Белгород, ул. Некрасова, 8/9

https://orcid.org/0000-0002-1678-1492PerutskiyD. N.ПеруцкийД. Н.
Russian Federation

Dmitriy N. Perutskiy – MD, PhD, Specialist of Ultrasound Diagnostics, Department of Functional Diagnostics.

8/9 Nekrasova ul., Belgorod, Belgorod Region, 308009

Перуцкий Дмитрий Николаевич – кандидат медицинских наук, врач отделения функциональной диагностики.

308009, Белгородская обл., Белгород, ул. Некрасова, 8/9

https://orcid.org/0000-0001-7292-0381BasarabA. I.БасарабА. И.
Russian Federation

Anna I. Basarab – MD, Cardiologist, Department of Urgent Сardiology with Intensive Care Unite.

8/9 Nekrasova ul., Belgorod, Belgorod Region, 308009

Басараб Анна Игоревна – врач-кардиолог отделения неотложной кардиологии с блоком интенсивной терапии.

308009, Белгородская обл., Белгород, ул. Некрасова, 8/9

St. Ioasaph's Belgorod Regional Clinical HospitalОГБУЗ «Белгородская областная клиническая больница Святителя Иоасафа»160920194743613692907201929072019Copyright ©; 2019, Basarab D.A., Ustyuzhin E.D., Perutskiy D.N., Basarab A.I.Copyright ©; 2019, Басараб Д.А., Устюжин Е.Д., Перуцкий Д.Н., Басараб А.И.2019Basarab D.A., Ustyuzhin E.D., Perutskiy D.N., Basarab A.I.Басараб Д.А., Устюжин Е.Д., Перуцкий Д.Н., Басараб А.И.https://creativecommons.org/licenses/by/4.0https://almclinmed.ru/jour/article/view/1084

The paper presents a  rare case of successful correction of an anterior mitral leaflet perforation. A 28-years old patient was referred with progressive heart failure symptoms at 18  weeks after he had a penetrating stab wound of the right ventricle. Massive pericardial effusion with cardiac tamponade risk and severe mitral valve insufficiency were found at examination. By the time of referral, spontaneous closure of the ventricular septal defect, which is an inevitable component of the “unhappy triad”, had happened. Accurate topical ultrasound diagnosis of the intracardial lesion that resulted from the penetrating wound of the left ventricular outflow allowed for a successful urgent mitral valve reconstruction with a xenopericardial patch and the insertion of a  28  mm MedEng annuloplasty band. To prevent any future pericardial constriction, subtotal pericardectomy by Cooley was performed.

Conclusion: Perioperative echocardiography and subsequent follow up by cardiologist are obligatory in all cases of precordial wounds after discharge from hospital. Timely surgery for traumatic mitral leaflet perforation allows for a successful valvuloplasty.

В статье представлен редкий случай успешной коррекции перфорации передней створки митрального клапана. Пациент 28 лет обратился с симптомами прогрессирующей сердечной недостаточности через 18 недель после проникающего колото-резаного ранения правого желудочка сердца. При обследовании выявлен массивный экссудативный перикардит с угрозой тампонады и тяжелая митральная недостаточность. На момент обращения произошло спонтанное закрытие неизбежного при «несчастной триаде» дефекта межжелудочковой перегородки. Четкая топическая ультразвуковая диагностика внутрисердечного повреждения в исходе сквозного ранения выходного тракта левого желудочка обеспечила выполнение успешной срочной пластики митрального клапана ксеноперикардиальной заплатой на жестком опорном кольце МедИнж 28 мм с хорошим результатом. Для предупреждения констрикции в исходе перикардита выполнена субтотальная перикардэктомия по D. Cooley.Заключение. При ранениях в области сердца необходимо проведение периоперационной эхокардиографии с последующим наблюдением кардиологом всех раненых, выписанных из хирургического стационара. Своевременное оперативное вмешательство при травматической перфорации створки митрального клапана позволяет успешно выполнить пластическую коррекцию порока сердца.

penetrating woundheart woundcardiac tamponademitral valve insufficiencyпроникающее ранениеранение сердцатампонада сердцанедостаточность митрального клапана1. Cappelen AH. Vulnus cordis: sutur af hjertet. Norsk Mag Laegevidensk. 1896;11:285–8.2. Rehn L. Uber penetrirenden herzwunden und herznaht. Arch Klin Chir. 1897;55:315–29.3. Tang AL, Inaba K, Branco BC, Oliver M, Bukur M, Salim A, Rhee P, Herrold J, Demetriades D. Postdischarge complications after penetrating cardiac injury: a survivable injury with a high postdischarge complication rate. Arch Surg. 2011;146(9):1061–6. doi: 10.1001/archsurg.2011.226.4. Degiannis E, Loogna P, Doll D, Bonanno F, Bowley DM, Smith MD. Penetrating cardiac injuries: recent experience in South Africa. World J Surg. 2006;30(7):1258–64. doi: 10.1007/s00268-005-0463-5.5. Kaljusto ML, Skaga NO, Pillgram-Larsen J, Tønnessen T. Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma center. Scand J Trauma Resusc Emerg Med. 2015;23:41. doi: 10.1186/s13049-015-0125-z.6. Asfaw I, Thoms NW, Arbulu A. Interventricular septal defects from penetrating injuries of the heart: a report of 12 cases and review of the literature. J Thorac Cardiovasc Surg. 1975;69(3): 450–7.7. Moront M, Lefrak EA, Akl BF. Traumatic rupture of the interventricular septum and tricuspid valve: case report. J Trauma. 1991;31(1):134–6. doi: 10.1097/00005373-199101000-00026.8. Genoni M, Jenni R, Turina M. Traumatic ventricular septal defect. Heart. 1997;78(3):316–8. doi: 10.1136/hrt.78.3.316.9. Mattox KL, Limacher MC, Feliciano DV, Colosimo L, O'Meara ME, Beall AC Jr, DeBakey ME. Cardiac evaluation following heart injury. J Trauma. 1985;25(8):758–65. doi: 10.1097/00005373-198508000-00005.10. Topaloglu S, Aras D, Cagli K, Ergun K, Deveci B, Demir AD, Korkmaz S, Sabah I. Penetrating trauma to the mitral valve and ventricular septum. Tex Heart Inst J. 2006;33(3):392–5.11. Vecht JA, Ibrahim MF, Chukwuemeka AO, James PR, Venn GE. Delayed presentation of traumatic ventricular septal defect and mitral leaflet perforation. Emerg Med J. 2005;22(7): 521–2.12. Domoto S, Tabata M, Kimura F, Niinami H. Clinical images of penetrating cardiac injury. Eur Heart J. 2016;37(36):2767. doi: 10.1093/eurheartj/ehv672.13. Connelly TM, Kolcow W, Veerasingam D, DaCosta M. A severe penetrating cardiac injury in the absence of cardiac tamponade. Interact Cardiovasc Thorac Surg. 2017;24(2):286–7. doi: 10.1093/icvts/ivw342.14. Han FY, Reyes KG, Bleiweis MS. Managing extensive mitral valve and ventricular septal injuries secondary to penetrating trauma. Eur J Cardiothorac Surg. 2018;53(1):284–5. doi: 10.1093/ejcts/ezx298.15. Skoularigis J, Essop MR, Sareli P. Usefulness of transesophageal echocardiography in the early diagnosis of penetrating stab wounds to the heart. Am J Cardiol. 1994;73(5):407–9. doi: 10.1016/0002-9149(94)90020-5.16. Ingraham A, Sperry J. Operative management of cardiac injuries: diagnosis, technique, and postoperative complications. Curr Trauma Rep. 2015;1(4):225–31. doi: 10.1007/s40719-015-0032-9.17. Соловьев ГМ, Попов ЛВ, Басараб ДА. Новый метод закрытия травматического дефекта межжелудочковой перегородки (редкий случай проникающего ранения левого желудочка). Кардиология. 2000;40(12):99–102. [Soloviev GM, Popov LV, Basarab DA. A novel method of closure of traumatic interventricular septal defect. A rare case of perforating wound of the left ventricle. Kardiologiia. 2000;40(12):99–102. Russian.]18. Özdemir AC, Yüksel V, Hüseyin S, Baltalarlı A. Aortic valve regurgitation and ventricular septal defect diagnosed 5 years after penetrating cardiac injury. Thorac Cardiovasc Surg. 2014;62(6):528–30. doi: 10.1055/s-0032-1331896.19. Гордеев МЛ, Наймушин АВ, Ташханов ДМ, Баутин АЕ, Бендов ДВ, Боткин ДА, Беспалов АА, Пескарева МА, Шаталкин ИВ, Гладилова ИВ, Нефедова ИН, Дюжилова ОИ. Анестезиологическое обеспечение, интенсивная терапия при множественном сквозном проникающем ранении груди с повреждением сердца и аорты (клинический случай). Экстренная медицина. 2018;7(3):328–36. [Gordeev M, Najmushin A, Tashkhanov D, Bautin A, Bendov D, Botkin D, Bespalov A, Piskareva M, Shatalkin I, Gladilova I, Nefedova I, Dyuzhilova O. Anesthetic management and intensive care in penetrating chest injury with multiple damage of heart and aorta (case report). Emergency Medicine. 2018;7(3):328–36. Russian.]20. Singh KE, Baum VC. The anesthetic management of cardiovascular trauma. Curr Opin Anaesthesiol. 2011;24(1):98–103. doi: 10.1097/ACO.0b013e32833ff3d6.21. Ezzine SB, Bouassida M, Benali M, Ghannouchi M, Chebbi F, Sassi S, Mighri MM, Touinsi H, Sassi S. Management of penetrating cardiac injuries in the Department of surgery, Mohamed Thahar Maamouri Hospital, Tunisia: report of 19 cases. Pan Afr Med J. 2012;11:54. doi: 10.11604/pamj.2012.11.54.1414.22. Rozycki GS, Feliciano DV, Ochsner MG, Knudson MM, Hoyt DB, Davis F, Hammerman D, Figueredo V, Harviel JD, Han DC, Schmidt JA. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999;46(4):543–51. doi: 10.1097/00005373-199904000-00002.23. Thorson CM, Namias N, Van Haren RM, Guarch GA, Ginzburg E, Salerno TA, Schulman CI, Livingstone AS, Proctor KG. Does hemopericardium after chest trauma mandate sternotomy? J Trauma Acute Care Surg. 2012;72(6):1518–24. doi: 10.1097/TA.0b013e318254306e.24. Cull JD, Bokhari F. Penetrating chest injury in the setting of a hemothorax: should pericardial windows replace echocardiograms? Am Surg. 2013;79(2):E56–7.25. Smith CA, Galante JM, Pierce JL, Scherer LA. Laparoscopic transdiaphragmatic pericardial window: getting to the heart of the matter. J Am Coll Surg. 2011;213(6):736–42. doi: 10.1016/j.jamcollsurg.2011.09.005.26.Hommes M, Nicol AJ, van der Stok J, Kodde I, Navsaria PH. Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma. Br J Surg.2013;100(11):1454–8. doi: 10.1002/bjs.9241.27.Jones TS, Burlew CC, Stovall RT, Pieracci FM, Johnson JL, Jurkovich GJ, Moore EE. Emergency department pericardial drainage for penetrating cardiac wounds is a viable option for stabilization. Am J Surg. 2014;207(6):931–4. doi: 10.1016/j.amjsurg.2013.08.042.28. Hsia RY, Mahadevan SV, Brundage SI. Penetrating cardiac injury from a wooden knitting needle. J Emerg Med. 2012;43(1):116–9. doi: 10.1016/j.jemermed.2010.06.027.29. Lindenbaum G, Larrieu AJ, Goldberg SE, Wolk LA, Ghosh SC, Ablaza SG, Fernandez J. Diagnosis and management of traumatic ventricular septal defect. J Trauma. 1987;27(11): 1289–93. doi: 10.1097/00005373-198711000-00015.30. Михеев АА, Залесов ВЕ, Кранин ДЛ, Овчаров РС, Хренов ЮВ, Кожемяка ИВ. Случай ушивания перфорации передней створки митрального клапана после сквозного пулевого ранения сердца. Грудная и сердечно-сосудистая хирургия. 2001;(5):68–9. [Mikheev AA, Zalesov VE, Kranin DL, Ovcharov RS, Khrenov YuV, Kozhemyaka IV. A case of suturing of the anterior mitral valve leaflet perforation after a penetrating gunshot heart wound. Russian Journal of Thoracic and Cardiovascular Surgery. 2001;(5): 68–9. Russian.]31. Clarke DL, Quazi MA, Reddy K, Thomson SR. Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa. J Thorac Cardiovasc Surg. 2011;142(3):563–8. doi: 10.1016/j.jtcvs.2011.03.034.32. Kumar S, Moorthy N, Kapoor A, Sinha N. Gunshot wounds: causing myocardial infarction, delayed ventricular septal defect, and congestive heart failure. Tex Heart Inst J. 2012;39(1): 129–32.33. Cottini M, Pergolini A, Ranocchi F, Musumeci F. The role of heart team approach in penetrating cardiac trauma: case report and review of the literature. Braz J Cardiovasc Surg. 2018;33(1): 99–103. doi: 10.21470/1678-9741-2017-0150.34. Barbosa FM, Quiroga JM, Otero AE, Girela GA. Aortic valve regurgitation with aorto-right ventricular fistula following penetrating cardiac injury. Interact Cardiovasc Thorac Surg. 2011;13(6):653–4. doi: 10.1510/icvts.2011.275297.35. Peng CF, Metzl MD, Taub CC. Penetrating cardiac wounds identified by three-dimensional transesophageal echocardiography. J Trauma. 2011;71(1):260. doi: 10.1097/TA.0b013e3181f8cad8.36. Antoniades L, Petrou PM, Eftychiou C, Nicolaides E. A penetrating heart injury resulting in ventricular septal defect. Hellenic J Cardiol. 2011;52(1):71–4.37.Harling L, Ashrafian H, Casula RP, Athanasiou T. Late surgical repair of a traumatic ventricular septal defect. J Cardiothorac Surg. 2014;9:145. doi: 10.1186/s13019-014-0145-1.38. Sugiyama G, Lau C, Tak V, Lee DC, Burack J. Traumatic ventricular septal defect. Ann Thorac Surg. 2011;91(3):908–10. doi: 10.1016/j.athoracsur.2010.08.071.39. Lee JW, Hwang JJ, Kim KD. Late iatrogenic coronary artery stenosis after penetrating cardiac trauma repair. J Trauma. 2011;71(5):E122. doi: 10.1097/TA.0b013e31821b259b.40. Sheikhi MA, Asgari M, Firouzabadi MD, Zeraati MR, Rezaee A. Traumatic left anterior descending coronary artery-right ventricle fistula: a case report. J Tehran Heart Cent. 2011;6(2): 92–4.41. Talving P, Branco BC, Plurad D, Inaba K, Shriki JE, Nguyen N, Lustenberger T, Demetriades D. Selective non-operative management of a left ventricular pseudoaneurysm after penetrating cardiac wound. J Emerg Trauma Shock. 2012;5(4):353–5. doi: 10.4103/0974-2700.102411.42. Imazio M, Hoit BD. Post-cardiac injury syndromes. An emerging cause of pericardial diseases. Int J Cardiol. 2013;168(2):648–52. doi: 10.1016/j.ijcard.2012.09.052.43. Pasteuning WH, Wonnink-de Jonge WF, van Berge Henegouwen DP, van der Aa MA, Penn OC. Acquired ventricular septal defect and mitral insufficiency without pericardial effusion after stab wound to the chest. J Am Soc Echocardiogr. 1998;11(5):483–6. doi: 10.1213/XAA.0000000000000528.44. Hines GL, Doyle E, Acinapura AJ. Post-traumatic ventricular septal defect, mitral insufficiency, and multiple coronary cameral fistulas. J Trauma. 1977;17(3):234–7. doi: 10.1097/00005373-197703000-00009.45. Caffery T, Robinson D, O'Neal H, Kahn A, Thurston S, Musso M. Delayed detection of a ventricular septal defect following penetrating trauma. J La State Med Soc. 2014;166(6):239–41.46. McCutcheon KR, Manga P. Delayed heart failure due to mitral valve perforation after stab chest. Eur Heart J Cardiovasc Imaging. 2014;15(3):315. doi: 10.1093/ehjci/jet153.47. Thandroyen FT, Matisonn RE. Penetrating thoracic trauma producing cardiac shunts. J Thorac Cardiovasc Surg. 1981;81(4):569–73.48. Doty JR, Cameron DE, Elmaci T, Salomon NW. Penetrating trauma to the tricuspid valve and ventricular septum: delayed repair. Ann Thorac Surg. 1999;67(1):252–3. doi: 10.1016/s0003-4975(98)01154-0.49. Midell AI, Replogle R, Bermudez G. Spontaneous closure of a traumatic ventricular septal defect following a penetrating injury. Ann Thorac Surg. 1975;20(3):339–42. doi: 10.1016/s0003-4975(10)64227-0.50. Lui AH, Glas WW, Bercu BA. Stab wound of the heart with tamponade and interventricular septal defect. Report of a case. J Thorac Cardiovasc Surg. 1965;49:517–22.51. Pejaković S, Mileusnić S. Interventricular defect of the septum caused by a stab wound of the heart. Srp Arh Celok Lek. 1967;95(1):75–9.52. Kieny R, Wolff F, Gross A, Mantz JM, Kurtz T, Kieny MT. Post-traumatic interventricular communication. Closure under extracorporeal circulation. Arch Mal Coeur Vaiss. 1975;68(1): 97–103.53. Bande A, Pisano GF, Sanna A, Scano F, Binaghi F. Interventricular communication secondary to a penetrating heart wound. A case description; a review of the literature. Minerva Cardioangiol. 1980;28(7–8):543–6.54. Bryan AJ, Angelini GD, Breckenridge IM. Spontaneous closure of a traumatic interventricular septal defect following a penetrating chest injury. Thorac Cardiovasc Surg. 1988;36(3): 172–3. doi: 10.1055/s-2007-1020072.55. Воронов АА, Куксинский ВЕ, Ильин АС. Оперативное лечение травматического дефекта межжелудочковой перегородки после ножевого ранения сердца. Грудная хирургия. 1989;(5):90–1. [Voronov AA, Kuksinskiy VE, Il'in AS. Surgical treatment for a post-traumatic defect of the interventricular septum after a knife wound of the heart. Thoracic Surgery. 1989;(5):90–1. Russian.]56. Take A, Yamaguchi T, Horimi H, Kato M, Hasegawa T, Kimura S. Blunt cardiac trauma resulting in ventricular septal perforation and mitral regurgitation due to papillary muscle rupture – a case report. Nihon Kyobu Geka Gakkai Zasshi. 1993;41(1):119–25.57. Carvalho AC, Echeverria NG, Gonçalves R, Telles CA, Andrade JC, Buffolo E. Late development of congestive heart failure in interventricular communication caused by penetrating wound, with pulmonary hypertension resolution after surgical correction. Arq Bras Cardiol. 1994;62(2):119–21.58. Gölbaşi Z, Ciçek D, Uçar O, Kaya D, Keleş T, Ciçekçiolu H, Aydodu S. Traumatic ventricular septal defect and mitral insufficiency after a Kebab's shish wound to the chest. Eur J Echocardiogr. 2001;2(3):203–4. doi: 10.1053/euje.2001.0074.59. Ali TA, Fatimi SH, Hasan BS. Transcatheter closure of a traumatic ventricular septal defect using an Amplatzer™ atrial septal occluder device. Catheter Cardiovasc Interv. 2013;82(4): 569–73. doi: 10.1002/ccd.24739.60. Tang L, Tang JJ, Fang ZF, Hu XQ, Shen XQ, Zhou SH. Severe mechanical hemolysis after transcatheter closure of a traumatic ventricular septal defect using the Amplatzer atrial septal occluder. Int Heart J. 2016;57(4):519–21. doi: 10.1536/ihj.15-407.61. Kharwar RB, Madan T, Thakkar B, Shukla A, Deshmukh J. Percutaneous Device Closure of a Post-Traumatic Ventricular Septal Rupture. JACC Cardiovasc Interv. 2016;9(17):1848–50. doi: 10.1016/j.jcin.2016.06.043.62. Argento G, Fiorilli R, Del Prete G. A rare case of a post-traumatic intraventricular defect. Ital Heart J Suppl. 2002;3(3):352–4.63. Berry C, Hillis WS, Knight WB. Transcatheter closure of a ventricular septal defect resulting from knife stabbing using the Amplatzer muscular VSD occluder. Catheter Cardiovasc Interv. 2006;68(1):153–6. doi: 10.1002/ccd.20718.