the need for intervention. It is also important to note that there have been case reports in which the initial examina- tion and transthoracic echocardiogram were normal, but delayed examinations revealed septal defects. 9,13 Therefore, it is imperative that the patient receive an echocardiogram prior to discharge, 14 as well as a follow-up echocardiogram at the first post-op clinic visit to determine whether a VSD has developed or whether there were changes in the pre- sentation of an existing VSD. Treatment of VSDs varies depending on hemodynamic stability of patients and size of the shunt ratio. Ventricular septal defects secondary to cardiac injury may not result in any physical symptoms or require corrective action. In many instances, posttraumatic VSDs resolve spontane- ously. 15,16 It is recommended, if the patient does not exhibit symptoms, that invasive intervention be postponed in order to determine whether the VSDwill close spontaneously. 12,15 However, closure of VSDs is indicated in the presence of hemodynamic instability, pulmonary hypertension, or en- larged left chambers. Traditionally, surgical interventions for VSD closure required sternotomy or thoracotomy. In 1988, the first transcatheter closure of a VSDwas reported in the literature. 17 Today, physiciansmay employ anAmplatzer VSD occluder, a device designed specifically for closure of VSDs. 18 In the present case, further investigation of the VSD may have resulted in less invasive correction, using one of these methods. SUMMARY In the current case, a holosystolic murmur was noted during the physical examination on the second day, and a transthoracic echocardiogram revealed a VSD. Because the patient was hemodynamically stable while intubated and many VSDs close spontaneously, it was decided that an at- tempt at extubation would be made. Once the patient was extubated, the left to right shunt increased with the mani- festations of heart failure, pulmonary overload, hypoxemia, and tachycardia. In retrospect, follow-up assessment of the holosystolicmurmur using cardiac catheterizationmay have resulted in corrective surgery prior to extubation. Emergent repair of the VSD was required. As the current case illus- trates, follow-up assessments are of paramount importance for patients who have sustained penetrating cardiac injuries. REFERENCES 1. Tintinalli JS. Tintinalli’s EmergencyMedicine: AComprehensive Study Guide , Seventh Edition. New York: McGraw Hill; 2011. 2. Kang N, Hsee, L, Rizoli S, et al. Penetrating cardiac injury: Overcoming the limits set by nature. Injury, Int J Care Injured 2009;40:919-927. 3. Asensio JA, Soto SN, Forno W, et al. Penetrating cardiac injuries: a complex challenge. Injury, Int. J. Care Injured 2001;32:533-543. 4. Rhee PM, Acosta, J, Bridgeman, A, et al. Survival after emergency department thoracotomy: Review of published data from the past 25 years. J Am Coll Surg 2000;190:288-298. 5. Molina E, Gaughan JP, Kulp H, et al. Outcomes after emergency
thoracotomy for penetrating cardiac injuries: A new perspective. Interactive Cardiovasc and Thorac Surg 2008;7:845-848. 6. Abbott JA, Cousineau M, Cheitlin M, et al. Late sequelae of penetrating cardiac wounds. J Thorac and Cariovasc Surg 1978;75:510-518. 7. Demetriades D, Charalambides C, Sareli, P, et al. Late sequelae of penetrating cardiac injuries. Br J Surg 1990;77:813-814. 8. Girard T, Kress, JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 2008;371:126-134. 9. Jeon K, Lim, W-H, Kang, S-H, et al. Delayed diagnosis of traumatic ventricular septal defect in penetrating chest injury: Small evidence on echocardiography makes big difference. J Cardiovasc Ultrasound 2010;18(1):28-30. 10. 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;73:407-409. 11. Sugiyama G, Lau C, Tak, V, et al. Traumatic ventricular septal defect. Ann Thorac Surg 2011;91:108-110. 12. JonesMB, Hunt JP, Glancy DL, et al. Ventricular septal defect from a gunshot to the buttock. J La State Med Soc 2009;161:148-152. 13. Antoniades L, Petrou, P, Eftychiou C, et al. A penetrating heart injury resulting in ventricular septal defect. Hellenic J Cardiol 2011;52:71-74. 14. Tang AL, Inaba K, Branco BC, et al. Postdischarge complications after penetrating cardiac injury: A survivable injury with a high postdischarge complication rate. Arch Surg 2011;146(9):1061-1066. 15. Dehghani P, IbrahimR, Collins N, et al. Post-traumatic ventricular septal defects: Review of the literature and a novel technique for percutaneous closure. J Invasive Cardiol 2009;21:483-487. 16. Glancy DL, Itscoitz SB, McIntosh CL, et al. Successful operative correction of intrapulmonary rupture of a post-traumatic left ventricular aneurysm: documentation of complete spontaneous closure of an associated ventricular septal defect. Am J Cardiol 1972;30:914-918. 17. Lock JE, Block PC, McKay RG., et al. Transcatheter closure of ventricular septal defects. Circulation 1988;782:361-368. 18. Fraisse A, Piechaud J-F, Avierinos J-F, et al. Transcatheter closure of traumatic ventricular septal defect: An alternative to surgical repair? Ann Thorac Surg 2002;74:582-584.
Dr. Caffery is an Assistant Professor in Louisiana State University Health Sciences Center’s School of Medicine and the ProgramDirector of the LSUHSC’s Emergency Medicine Residency Program in Baton Rouge. Dr. Robinson recently completed his residency at LSUHSC’s Emergency Medicine Residency Program in Baton Rouge, and he is currently an Emergency Medicine Physician at St. Tammany Parish Hospital. Dr. O’Neal is an Assistant Professor of Clinical Medicine, Pulmonary & Critical Care Medicine, LSUHSC - Baton Rouge. Drs. Kahn and Thurston are Assistant Professors of Surgery in the CVT Surgical Center at the LSUHSC in New Orleans. Dr. Musso is the Academic Research Director for LSUHSC’s Emergency Medicine Residency Program in Baton Rouge.
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