Abstract

Penetrating cardiac injuries are rare, but often fatal. They may present with different manifestations. A 30-year-old male patient was admitted with self-inflicted left parasternal stab wound in the second intercostal space. Computed tomography revealed pericardial and pleural effusion. Echocardiography and aortography showed severe aortic regurgitation and aorto-right ventricular communication mimicking a congenital sinus Valsalva aneurysm rupture. The patient was operated and aortic leaflet repair with a pericardial patch and closure of the communication on both aortic and right ventricular sides were performed. In conclusion, although such traumatic injuries are rare, they may be life-threatening and, therefore, requires prompt treatment.

Introduction

Penetrating cardiac injuries are rare, but represent a high mortality in most cases. The injury is usually nonaccidental, predominantly sustained by males, and the mortality rate is about 60%, which further increases where pericardial tamponade is absent.[1,2] In a recent large series, 86% of injuries constituted single chamber injury, predominantly right ventricle (46%) and left ventricle (24%), whereas multi-chamber injuries were seen in 18% of cases. Patients typically manifest with signs of cardiac tamponade, cardiac arrest, or signs of extremis from exsanguination.[2]

Congenital sinus Valsalva aneurysms are rare abnormalities often presenting with rupture. In more than 80% of cases, the rupture originates from the right coronary sinus (RCS). Aorto-right ventricular connection is observed in 65% of cases.[3,4]

Herein, we report a case of aorto-right ventricular communication concomitant with aortic regurgitation due to self-inflicted stab wound injury.

Case Presentation

A 30-year-old male patient was admitted to the cardiology department with chest pain. He had a selfinflicted left parasternal stab wound in the second intercostal space two days ago after heavy alcohol intake. He did not remember the type of knife used. He was examined in a rural medical center and the skin wound was sutured. The patient reported no complaint subsequently. Echocardiography and aortography revealed aortic valve regurgitation due to a defect in the right coronary cusp (RCC) and aorto-right ventricular communication (Video 1).

Pericardial and bilateral pleural effusion was noted on echocardiography and computed tomography (CT) scan (Figure ). He had no signs of tamponade or pathological findings, except for the sutured wound (Figure ).

He was scheduled for an urgent operation and a written informed consent was obtained. A median sternotomy was performed. Due to the possibility of aortic injury, right femoral artery was cannulated to initiate cardiopulmonary bypass (CPB) immediately following pericardiotomy. Hematoma and defibrinated blood were present in the pericardial space. A very little adventitial hematoma was located in the left lateral side of the aorta above the sinotubular junction. The right atrium was cannulated and CPB was initiated. Transverse aortotomy was performed.

There was a slit-like linear opening on RCS connected with right ventricular cavity (Figure ). There was also a 2¥1 cm defect in the RCC. Transverse right ventriculotomy was performed to visualize the opening of the defect and a slit-like linear opening was noted (Figure ).

The aortic side of the opening was sutured with two Teflon pledgeted sutures (Figure ) and the right ventricular side with the Teflon felt on both sides (Figure ). The defect in the RCC was repaired with a fresh pericardial patch.

Aortotomy was closed and the patient was weaned from CPB. The postoperative course was uneventful and postoperative echocardiography revealed no aortic regurgitation or aorto-right ventricular communication. In the first year of follow-up, the patient is still stable with normal echocardiographic findings.

Discussion

Penetrating cardiac injury is often fatal with a mortality rate over 60%. Multi-chamber injuries constitute a lower percentage of cases with a predominant single right ventricle injury.[1,2] The present case is unique, as it is a late admission and had no signs of hemodynamic compromise, despite a great injury with an aorto-right ventricular communication.

Such an injury might have caused a great hemodynamic compromise due to signs of exsanguination or cardiac tamponade. However, our case had no complaints at the time of injury and was admitted two days later due to chest pain.

Surprisingly, pericardial effusion was not much and did not cause tamponade within two days. There was a small adventitial hematoma in the left lateral side of the aorta, however, there was neither hemorrhage from the aorta nor a visible aortic injury site. In this case, the injury mimicked a ruptured congenital sinus Valsalva aneurysm, although it was truly a multichamber injury involving the ascending aorta. The RCC was also injured and repaired with a pericardial patch.

There is a limited number of reports in the literature showing similar pathologies.[5,6] Such an injury may be fatal at the time of injury, and it is quite surprising that our patient survived. In addition, he did not remember the type of knife used, although we suspected a skewer-like thin and long tool.

In conclusion, penetrating cardiac injuries may represent as unique pathologies and require major interventions. If possible, repair should be preferred, if valvular pathologies exist.

Declaration of conflicting interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.