Electrocardiographic features suggestive of a transmural anterior myocardial infarction with resultant left ventricular aneurysm formation were found in a 22-year-old man who had sustained a ballistic missile injury to his chest

Diamond, T. H.

Myburgh, D.P.

Smith, R

Steingo, L

English

AJOL - African Journals Online

SA MEDICAL JOURNAL VOLUME 63 1 JANUARY 1983 27Electrocardiographic features suggestiveof a left. ventricular' aneurysm followinga high-velocity missile injuryA case reportT. H. DIAMOND, R. SMITH, D. P. MYBURGH, L. STEINGOSummaryElectrocardiographic features suggestive of atransmural anterior myocardial infarction withresultant left ventricular aneurysm formation werefound in a 22-year-old man who had sustained aballistic missile injury to his chest.S Atr Ued J 1983; &3: 27-28.High-velocity missile injuries to the heart may either be causeddireerly by the missile or by shrapnel (haemopericardium,tamponade or exsanguination from myocardial lacerations), orindirectly by the transmission of the high energy of the bullet tothe nearby myocardium.l-4 This 'shock wave' may extend up to adistance of 20 times the diameter of the missile.' Any injury ofthis type occurring within the left hemithorax may thereforeresult in massive myocardial necrosis.I,6.7 The laner would pre-sent early as cardiogenic shock or rhythm disturbances, orFig. 1. Resting ECG illustrating persistent ST-segment elevation.Institute for Aviation Medicine, Verwoerdburg, TvlT. H. DIAMOND, M.B. B.CH.R. SMITH, ,},\.B. B.CH.D. P. MYBURGH, SM., M.B. CH.B., FAe.e.L. STEINGO, M.B. B.CH., F.e.P. (S.A.) (present address: CardiologyDept, University of Witwatersrand, Johannesburg)Da,e m:eived: 19 January 1982.months later as myocardial necrosis mimicking an extensivemyocardial infarction,I.6.SThe electrocardiographic and echocardiographic findings in acase of the late complications of high-velocity missile injury tothe heart, viz. 'shock wave' myocardial necrosis with secondaryaneurysm formation, are presented.Case reportA 22-year-old White man applying for a private pilot's licencewas investigated after having been diagnosed on electrocardio-graphic criteria as having had an extensive anterior myocardialinfarction. He had been healthy until 48 moriths previously, atwhich time he had been admined to hospital as a victim of asniper with an Armourlite assault rifle in Ireland. He had receiveda single bullet injury to the left hemithorax. Further details werevague, but he underwent an emergency left explorative thoraco-tomy. Large vessels were sutured and shrapnel fragments wereremoved, but no cardiac surgery was performed. The onlyimmediate postoperative complication was respiratory failure.The patient was artificially ventilated for 2 weeks, and thereaftermade a slow recovery with no further complications. No evi-dence of cardiac damage was revealed and the patient was dis-charged. Eleetrocardiographic findings were not available to us.His history negated any cardiovascular impairment, angina orlimitation in effort tolerance. He plays regular contact sport suchas soccer and rugby. Risk factors for atherosclerosis included hissmoking (10 cigarenes per day for the previous 5 years).Fig. 2. Stress ECG illustrating exercise-induced ST-segmentelevation.28 SA MEDIESE TYDSKRIF DEEL 63 1 JANUARIE 1983The patient looked clinically healthy and was well built. Theheart rate was 75/min and the blood pressure was 108170mmHg. There were no signs ofcardiac failure. A left parasternalcardiac impulse was palpable. On auscultation, in addition to thenormal heart sounds, a fourth heart sound was audible. The restof the clinical examination was negative.The ECG (Fig. 1) recorded 48 months after injury showeddeep Q waves in leads I, aVL and V2-V6, with ST-segmentelevation in leads V2-V4, compatible with an extensive anteriormyocardial infarction or necrosis. A stress ECG (Fig. 2) at thetime showed a further increase in ST-segment elevation in leadsV2-VS, thereby increasing the likelihood of his having an asso-ciated left ventricular aneurysm. 9 A 24-hour Holter ECG wasnon-contributory and a chest radiograph was within normallimits.Fig. 3. Top: echocardiogram showing the long-axis view of theleft ventricle (apex towards the left). Bottom: idealized diagram ofabove, illustrating the apical thrombus (TH = thrombus; LV = leftventricle; LA = left atrium; AO = aorta).A two-dimensional echocardiogram using a Toshiba phased-array imaging system demonstrated the typical features of a leftventricular apical aneurysm (Figs 3 and 4). A thrombus was alsonoted in the aneurysm. The accuracy of two-dimensional echo-cardi0fcra{'hy in the detection of ventricular aneurysms has beennoted. 0.\ The aneurysm appears as a bulge with a shelf-likeseparation from the normal ventricular myocardium.In view of the patient's age, history and the cardiovascularfindings, we would like to postulate that the cause of the leftFig. 4. Top: echocardiogram showing an apical four-chamberview. Bottom: idealized diagram of above, illustrating the pre-sence of a calcified thrombus in the apical aneurysm of the leftventricle (AN = aneurysm).ventricular aneurysm and the electrocardiographic findings wasthe myocardial necrosis caused by the high-velocity missile. Wewould again like to stress this important complication of a high-energy missile injury - 'shock wave' tissue necrosis and aneu-rysm formation.REFERENCES1. Pamley LF, Symbas PN. Traumatic heart disease. In: Hurst JW, ed. TheHearc. New York: McGraw-Hill, 1978: 1683-1693.2. RansdeU HT, Glass H. Gunshot wounds of the hean: review of 20 cases. Am]Surg 1960; 99: 788-797.3. Charters AC, Charters Ae. Wounding mechanism ofvery high velocity projec-tiles.] Trauma 1976; 16: 464-470.4. Symbas PN, DiOrio DA, Tyras DH, Ware RE, Hatcher CR. Penetratingcardiac wounds: significant residual and delayed sequelae.] Thorac CardiovascSurg 1973; 66: 526-532.5. Du Plessis DJ. Principles o! Surgery. Bristol: John Wright & Sons, 1973; 28-30.6. Jones FL. Transmural myocardial necrosis after oonpenetrating cardiactrauma. Am] Cardiol 1970; 26: 419-422.7. De Muth WE, Baue AE, Odom JA. Conrusions of the hean.] Trauma 1967; 7:443-455.8. Harthome JW, Kantrowitz PA, Dinsmore RE, Sanders CA. Traumaticmyocardial infarction: report of a case with normal coronary angiogram. AnnImern Med 1967; 66: 341-344.9. Sriwatranakomen S, Ticzon AR, Zubritsky SA, Blobner CG, Rice M, DuffyFe. S-T segment elevation during.exercise: electrocardiographic and arterio-graphic correlation in 38 patients. Am] Cardiol 1980; 45: 762-768.10. Barren MJ, Charuzi Y, Corday E. Ventricular aneurysm: cross-sectional echo-cardiographic approach. Am] Cardiol 1980; 46: 1133-1137.11. Weyman AE, Peskoe SM, Williams ES, Dillon JC, Feigenbaum H. Detectionof left ventricular aneurysms by cross-sectional echocardiography. Circulation1976; 54: 939-944.

Electrocardiographic features suggestive of a left. ventricular' aneurysm following a high-velocity missile injury

https://www.ajol.info/index.php/samj/article/download/160499/150070

Electrocardiographic features suggestive of a left. ventricular' aneurysm following a high-velocity missile injury

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online