Intracardiac shunts are rarely encountered as sequelae of non-penetrating heart trauma and their clinical manifestations may often be unrecognized in the multi-injured patient. However, they are serious complications and their diagnostic approach is not always feasible.

Anninos, Hector

Dedeilias, Panagiotis

Gounopoulos, Pantelis

Koroneos, Apostolos

Politis, Panagiotis

Hospital Chronicles (E-Journal)

Left Ventricle to Right Atrium Shunt Secondary to Blunt Chest Trauma.  A Case ReportHector Anninos, MD, Panagiotis Politis, MD, Pantelis Gounopoulos, MD, Apostolos Koroneos, MD, Panagiotis Dedeilias, MDI N T R O D U C T I O NIntracardiac shunts are rarely encountered as sequelae of non-penetrating heart trauma and their clinical manifestations may often be unrecognized in the multi-injured patient. However, they are serious complications and their diagnostic approach is not always feasible. We hereby present a case of a young man with a left ventricle to right atrium communication after blunt thoracic trauma sustained during a car accident. C A S E  R E P O R TA 26-year-old man with nonsignificant personal and family medical history, was admitted to the hospital after suffering a car accident. At admission he was fully awake and oriented, with a Glasgow coma scale (GCS) 15/15. He was slightly tachypneic, he had a heart rate of 110/min and a blood pressure 80/50 mm Hg. On auscultation there was a decrease in vesicular breath sounds in the lower areas of the lung and a systolic murmur 3/6 heard diffusely in the precordial area.The electrocardiogram (ECG) revealed incomplete right bundle branch block (RBBB) with left posterior hemiblock (LPH) (Figure 1). The patient displayed elevated hepatic liver enzymes (aspartate aminotransferase-AST 455 IU, alanine aminotrasnferaase-ALT 543 IU, normal <40 IU), creatine phosphokinase-CPK 1388 (normal <190), CPK-MB 71 (normal <18), high-sensitivity cardiac troponin T-hsTnT 245 ng/ml (normal <14, grey zone 14-53). The white blood cell count reached 22000/mm3 and the hemoglobin was 14.5 g/dl. The rest of the blood analysis did not show any abnormal values. The patient underwent chest computed tomography (CT) scanning which displayed bilateral pleural effusions with compression atelectasis, fractures of the third, fourth and fifth right costal ribs, contusion in the right lung, and rupture of the aortic isthmus with the presence of pseudoaneurysm and mediastinal hematoma. The abdominal CT scan was normal.The patient was transferred to the catheterization laboratory and aortography was performed which confirmed the CT findings. No other site of blood extravasation was found. A stent was inserted into the descending aorta at the isthmus level. Subsequently he was admitted in the ICU and placed under close monitoring. He was hemodynami-cally stable at the time (heart rate 100/min, blood pressure 105/65 mmHg) and arterial blood gas (ABG) examination showed pH 7.42, PCO2 30 mmHg, PO2 132 mmHg, VIDEO SESSIONDepartments of Intensive Care Medicine and Cardiothoracic Surgery, Evagelismos Hospital, Athens, GreeceHOSPITAL CHRONICLES 2014, VOLUME 9, SUPPLEMENT 1: 107–110Corresponding author:Hector Anninos, MD E-mail: ekanninos@yahoo.comKEy wORDS: intracardiac communication; non-penetrating injury; echocardiographyAbbreviAtionsCT = computed tomographyECG = electrovardiogramICU – intensive care medicineLPH = left posterior hemiblockRBBB = right bundle branch block108HOSPITAL CHRONICLES 2014, VOLUME 9, SUPPLEMENT 1: «ATHENS CARDIOLOGY UPDATE 2014»and a bicarbonate level of 22mEq/L while receiving fraction of inspired O2 of 60%. The oxygen saturation in blood drawn from the superior vena cava (ScvO2) was measured at 60%. Due to this borderline value and the systolic murmur heard on cardiac auscultation, a transthoracic cardiac ultrasound was performed, which disclosed an abnormal blood flow between the left ventricle and the right atrium without any remarkable findings regarding the right chambers (Figure 2). A traumatic rupture in the aortic root creating a shunt towards the right atrium was presumed. A right heart catheterization followed demonstrating O2 step-up at the right atrium level (hemoglobin oxygen saturation in superior vena cava, right atrium, right ventricle and pulmonary artery was 46%, 80%, 85% and 85% respectively).With the diagnosis of the intracardiac shunt confirmed, surgery was undertaken by the cardiac surgeon who repaired the shunt with placement of a synthetic patch. Following the operation, the patient had an uncomplicated course and was discharged after 28 days of hospitalization.D I S C U S S I O NAcquired left ventricular-to-right atrial communications are relatively uncommon complications, most often attribut-able to surgical procedures, trauma, endocarditis, myocar-dial infarction or even endomyocardial biopsy.1-3 Most cases represent postoperative complications. Blunt chest trauma is scarcely reported in the literature as a cause of such an injury.4-6 Usually myocardial contusion dominates the picture in non-penetrating heart traumas, although ventricular septal ruptures have been reported. Unfortunately, even in cases of intracardiac rupture the clinical presentation is non-specific and can be underestimated in the context of more predominant injuries. The ECG shows findings that can be attributed to electrolyte disturbances, acid-base imbalance, hypoxia or hy-povolemia, which are all relatively common in thoracic injuries. Atrio-ventricular conduction disturbances have been reported although this was not the case in our patient.7,8FIgURE 1. Electrocardiogram showing incomplete right bundle branch block (RBBB) with left posterior hemiblock (LPH). LEFT VENTRICLE TO RIGHT ATRIUM SHUNT SECONDARY TO BLUNT CHEST TRAUMA109Though non-diagnostic, ECG findings can raise high de-gree of suspicion and prompt further evaluation by ultrasonog-raphy which can demonstrate a pathological flow and establish the diagnosis. The echocardiographic study should be detailed to discriminate tricuspid regurgitation jet from the left ventri-cle to right atrium shunt. However, transthoracic examination may be flawed due to suboptimal visualization especially in multi-trauma patients and in that case the transesophageal approach can be helpful, after the stenting procedure in case of aortic trauma.9,10 In selected cases, contrast enhanced CT can be of diagnostic value.11,12 If the shunt is significant, hemodynamic deterioration may occur and this should prompt rapid surgical closure of the communication. In our case the initial hemodynamic instabil-ity was attributed to the aortic trauma and after the stent was positioned, the patient indeed recovered from hypotension and shock. The intracardiac shunt was presumed mostly on the basis of the physical findings. In conclusion, non-penetrating cardiac trauma can some-times cause significant intracardiac damage leading to rupture of cardiac structures and producing pathological shunts. With respect to their size and location, these lesions can produce a variety of clinical features ranging from complete absence of symptoms to rapid hemodynamic compromise and shock. After blunt chest trauma one should always be alert for the pres-ence of such complications and regular physical examination is necessary to detect new cardiac murmurs which will guide further evaluation. Transthoracic ultrasound is a keystone examination but transesophageal views or CT may be needed in some cases.R E F E R E N C E S 1. Katta S, Akosah K, Stambler B, Salter D, Guerraty A, Mohanty PK. Atrioventricular fistula: an unusual complication of en-domyocardial biopsy in a heart transplant recipient. J Am Soc Echocardiogr 1994;7:405-409. 2. Mohapatra S, Singh Minhas H, Virmani S, Bihari Mishra B, Mukherjee K, Banerjee K. Acquired left atrial to right ventricu-lar shunt with mitral valve incompetence. A rare sequela after repair of atrioventricular septal defect. Tex Heart Inst J 2009; 36:69-71. 3. Sinisalo JP1, Sreeram N, Jokinen E, Qureshi SA. Acquired left ventricular-right atrium shunts. Eur J Cardiothorac Surg 2011; 39:500-506. 4. Kreuzer E, Beyer J. Isolated left ventricular--right atrial shunt after blunt chest trauma. Thoraxchir Vask Chir 1978; 26:398-401. 5. Sasaki N and Shimoyama. Acquired supravalvar type of left ventricular to right atrial communication following non-pene-trating cardiac trauma caused by traffic accident. Heart 2003; 89: 341.  6. Alnashawati G1, Yandam G, Huel JD, Termet H, Chuzel M. A case of left ventricle-right atrium defect caused by nonpenetrat-FIgURE 2. Pathological flow between left ventricle and right atrium (a, b) and mild tricuspid regurgitation (c). LV=left ven-tricle, RV=right ventricle110HOSPITAL CHRONICLES 2014, VOLUME 9, SUPPLEMENT 1: «ATHENS CARDIOLOGY UPDATE 2014»ing injury of the thorax. Ann Chir 1990; 44:98-101. 7. Portet N, Riu B, Bounes V, Minville V, Fourcade O. Left ventric-ular-right atrial communication with third-degree atrioventricu-lar block after thoracic trauma. J Emerg Med 2012;43:e385-388. 8. Venkatesh G, Lonn EM, Holder DA, Williams WG, Mulji A. Acquired left ventricular to right atrial communication and complete heart block following nonpenetrating cardiac trauma. Can J Cardiol 1996;12:349-352. 9. Kaye P, O’Sullivan I. Myocardial contusion: emergency investi-gation and diagnosis. Emerg Med J 2002;19:8-10. 10. García-Fernández MA, López-Pérez JM, Pérez-Castellano N, et al. Role of transesophageal echocardiography in the assess-ment of patients with blunt chest trauma: correlation of echo-cardiographic findings with the electrocardiogram and creatine kinase monoclonal antibody measurements. Am Heart J 1998; 135:476-481. 11. Restrepo CS, Gutierrez FR, Marmol-Velez JA, Ocazionez D, Martinez-Jimenez S. Imaging patients with cardiac trauma. Ra-diographics 2012;32:633-649. 12. Huguet M, Tobon-Gomez C, Bijnens BH, Frangi AF, Petit M. Cardiac injuries in blunt chest trauma. J Cardiovasc Magn Reson 2009;11: 35. 

Left Ventricle to Right Atrium Shunt Secondary to Blunt Chest Trauma. A Case Report

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Left Ventricle to Right Atrium Shunt Secondary to Blunt Chest Trauma. A Case Report

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