Trauma Monthly. 2013 Sep;18 (2): 95-7.
Undetected Aorto-RV Fistula With Aortic Valve Injury and Delayed Cardiac
Published Online 2013 August 11.
Tamponade following a Chest Stab Wound: A Case Report
2 Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
+98-5118525209, Fax: +98-5118437840, E-mail: email@example.com.
1, *, Mohammad Abbasi Tashnizi
1, Ali Asghar Moeinipour
1 Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran
*Corresponding author: Jamil Esfahanizadeh, Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, P. O. Box: 9137913316Mashhad, IR Iran.Tel.:
Received: April 30, 2013; Revised: May 27, 2013; Accepted: Jun 13, 2013
Introduction: Although a few patients will survive after penetrating cardiac injuries, some of them may have unnoticeable intracardiac
Case Presentation: A 19 year-old man referred with an aorto-right ventricular fistula accompanied with aortic regurgitation and delayed
months after trauma.
clinical examinations and serial echocardiography should be performed. In addition, cardiac injuries should be repaired during the same
Keywords: Heart Injuries; Cardiac Tamponade; Aorta; Fistula
condition andpatients who survive, are rarely without
Acute cardiac tamponade due to bleeding into the peri-
almost always leads to death at the accident scene (1). On
al clinical feature of heart stab wounds (2). Patients with
and great vessels injuries which often require emergency
survive (3). Also, such patients may require additional
nosed during resuscitation (4).Three to five percent of all
ac injuries involving valves, intra-arterial/ventricular sep-
early and late outcomes of patients (5). Moreover, the
complicated. One of the rare post penetrating cardiac
In one report, it comprised 0.5% of all intracardiac inju-
injuries. The combination of aorto-right ventricular fistula with aortic valve injury is rare.
tamponade following a stab in the chest. The patient was scheduled for fistula repair, aortic valve replacement and pericardectomy two
Conclusions: To prevent missing intracardiac injury and also late cardiac injury complications, in all pericordial stab wounds, serial
Implication for health policy/practice/research/medical education:
careful cardiac evaluation to exclude injury.
License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
The aim of this case presentation is to emphasize that penetrating thoracic and parasternal trauma, even when devoid of cardiac symptoms, require
Copyright © 2013, Trauma Research Center; Licensee Kowsar Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution
is properly cited.
Penetrating cardiac injury is a serious life-threatening
cardiac symptoms and sings during initial evaluation.
cardium is the most common clinical presentation, and
the other hand, delayed cardiac tamponade is an unusu-
penetrating cardiac wounds present a variety of heart
thoracotomy and cardioraphy and about half of them
surgical repair for intracardiac injuries that are not diag-
penetrating heart injuries have concomitant intracardi-
tum, coronary arteries and conductive system that affect
intracardiac injuries make the patient`s situation more
injuries is aorto-right ventricular fistula (Ao-RV Fistula).
ries (6). Sometimes, it may be associated with aortic valve
the first traumatic Ao-RV fistula in 1945(8). The first post
by MacQuot in 1920 (2, 9). So far, 19 cases of Ao- RV fistula
literature (7, 10-12). Herein, we report a case.
2. Case Presentation
wound (1.5cm knife wound in the left 4th intercostal
manage hemopnumothorax, a chest tube was inserted
symptoms. At that time, because of no observed cardiac
the general surgeon, thus, no cardiac evaluation such as
(CT) scan was performed. Two months later, he referred
and distending jugular veins. Lung sounds were clear but
was heard at the left sternal border (BP = 85/40mmHg, PR
injury and aortic regurgitation (AR) (7). King repaired
penetrating delayed cardiac tamponade was reported
with aortic valve injury have been reported in the English
A 19-year -old healthy man, who sustained a single stab
space para-sternally) was admitted to a local hospital. To
and after 3 days the patient was discharged without any
symptoms or signs, cardiac injury was not suspected by
echocardiography or thoracic computed tomography
to evaluate dyspnea. He had severe shortage of breath
heart sounds were decreased and a continuous murmur
Esfahanizadeh J et al.
Trauma Mon. 2013;18(2)
= 135/min, RR = 35/min, T = 38.5οC). In addition, the elec-
roentgenogram indicated an increased cardiac silhou-
confirmed a massive pericardial effusion. Also, severe
ration and a defect between the right Valsalva sinus and
scheduled for an urgent operation for post traumatic de-
dian sternotomy, a thickened and inflamed pericardium
In addition, the epicardium was edematous with some
ated. Specimens of pericardial tissue and fluid were sent
cardiopulmonary bypass and cardiac arrest were done.
nary cusp was found (Figure 1). Moreover; a 7mm defect
revealed (Figure 2).
trocardiogram showed sinus tachycardia, and the chest
ette that was globular. Transthoracic echocardiography
aortic regurgitation caused by right coronary cusp perfo-
right ventricle (RV) were demonstrated. The patient was
layed tamponade and also intracardiac defects. After me-
(4mm) which was full of debris and old clots was noticed.
adhesions. About 800cc sanguineous fluid was evacu-
for culturing. Then, using aorto-bicaval cannulation,
After aortotomy, a 10mm perforation in the right coro-
in the right coronary sinus that opened into the RV was
Figure 1. Traumatic Defect of Right Coronary Cusp (Arrow)
Figure 2. Aortic view of Aorto-RV Fistula (Arrow)
A ventriculotomy was performed through the infun-
nary valve in the septum which connected to the aorta.
Tex patch and continuous 4-0 prolene suture. Repairing
because the pericardium was inflamed. Therefore, the
No.23. Finally, in order to prevent constrictive pericardi-
an emergency operation, TEE was not available at that
postoperatively. After surgery, the patient`s hospital
phy demonstrated no residual shunt and pericardial
tricle had good function. During 2 years of clinical fol-
la accompanied with aortic regurgitation and delayed
sented with a simple stab wound into anterior chest
sion and managed only for left hemopnumothorax. Two
ade and post traumatic intracardiac defects. The patient
usual and rare namely showing no initial cardiac symp-
lesions (Ao-RV Fistula and aortic valve injury) and also,
ing cardiac trauma.
etrating trauma, even without cardiac symptoms and
diac evaluation is necessary to exclude probable cardiac
complications. In the past, the incidence of post trau-
5% (5). However, thanks to echocardiography and color-
raphy (TEE), these simultaneous lesions have been re-
common post penetrating intracardiac lesion is ventric-
injuries have been reported sporadically in traumatic
a connection between the infundibulum of the RV and
foration created by the knife tip. Aorto-RV fistula due to
with aortic valve injury and aortic regurgitation (7). Af-
dibulum. The defect was located 1cm below the pulmo-
The fistula was repaired via ventriculotomy using a Gor-
the aortic valve with pericardial patch was not possible
aortic valve was replaced by a mechanical prosthesis
tis, bilateral pericardectomy was performed. As this was
time the center; the patient was only evaluated with TTE
stay was uneventful and postoperative echocardiogra-
effusion. The prosthetic aortic valve and left/right ven-
low up, the patient has been asymptomatic with normal
Our case referred with an aorto-right ventricular fistu-
tamponade following a stab in the chest. The case pre-
wall, whose cardiac injury was missed at the first admis-
months later, he referred with delayed cardiac tampon-
displayed three aspects of heart injury which are un-
toms and signs, unnoticing two important intracardiac
delayed cardiac tamponade as late sequel of penetrat-
This presentation demonstrates that para-sternal pen-
signs, may have cardiac and intracardiac injuries. Car-
injury. Ignoring cardiac injury can lead to late cardiac
matic intracardiac lesions was reported to be less than
flow Doppler, especially transesophageal echocardiog-
ported to be about 20% in recent decades (13). The most
ular septal defect (VSD) (14). Mitral and tricuspid valves
patients (4, 15). Our patient had a rare heart injury with
right Valsalva sinus of the aorta and also aortic valve per-
injury is rare and in 35% of cases, it can be accompanied
Esfahanizadeh J et al.
Trauma Mon. 2013;18(2)
ter traversing through the chest wall, a pericordial stab
tear posterior wall of infundibulum (Conus). Then it
behind the conus. At first, the Ao-RV fistula can be toler-
ter a period of time (days or even years), it leads to heart
importance of physical examinations, the continuous
third of the patients on admission. Also, this murmur
following trauma. The mean interval time to detect
Therefore, a traumatic Aorto-RV fistula maybe missed
echocardiography provides useful information. How-
time, bleeding wounds and chest tube, pneumothorax
raphy may not reveal cardiac damage. Consequently, it
our patient was managed only for a stab wound in the
tracardiac injuries (Ao-RV fistula and aortic valve injury)
undergo any serial clinical and echocardiograph evalu-
cal picture was a post traumatic delayed pericardial ef-
a missed penetrating cardiac injury may rarely lead to
17). A combination of post traumatic Ao-RV fistula with
ade, similar to the current presentation, was reported
cause postpericardiotomy syndrome, infectious peri-
mend performing echocardiography for every patient
admission to the emergency department and for up to
occur after injury (2).
the chest, serial physical examinations and serial trans-
should be performed to exclude intracardiac injuries. In
pericardial or intracardial injury ought to be evaluated
penetrates the anterior wall of infundibulum which can
goes through the wall of right Valsalva sinus located just
ated well and the patient may be asymptomatic. But, af-
failure and therefore, needs to be repaired. Despite the
murmur of this entity can be detected in only one-
can be heard in 34% of other cases more than one week
the murmur is reported to be 59 days after trauma (7).
at first. Furthermore, to diagnose intracardiac injuries,
ever, in a trauma patient (emergency situation, lack of
and poor echo-window condition) initial echocardiog-
is advised to do serial echocardiography (16). Although
chest and hemopnumothorax, these two important in-
were missed at the first admission because he did not
ations. Then two months later, the major patient`s clini-
fusion and tamponade. It is important to consider that
delayed pericardial effusion and cardiac tamponade (2,
aortic valve perforation and delayed cardiac tampon-
by Kaya (11). Traumatic delayed pericardial effusion can
carditis and secondary bleeding. Rondon et al. recom-
with penetrating chest injury as soon as possible after
six months, because delayed pericardial effusion may
As cardiac injury can occur in every pericordial stab in
thoracic or even transesophageal echocardiography
order to prevent late cardiac complications, every intra-
and repaired at the same hospital stay.
University of Medical Sciences.
This study was financially supported by the Mashhad
mad Abbasi Tashnizi; Critical revision:.Aliasghar Moeini-
Draft: Jamil Esfahanizadeh; Acquisition of data: Moham-
pour; Conception and design: Alireza Sepehri Shamloo.
University of Medical Sciences.
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