Ventricular septal rupture presented with chronic heart failure symptoms: a case report

BACKGROUND

Ventricular septal rupture (VSR) is a rare mechanical complication following acute myocardial infarction, with very high mortality rate. Haemodynamic deterioration and cardiogenic shock is common in such cases. Rarely, however, patients may show only signs of chronic heart failure or be completely asymptomatic.

CASE SUMMARY

We report a case of a 72-year-old male patient with VSR following a transmural myocardial infarction. He sought medical attention only after gradually experiencing symptoms of chronic heart failure, weeks after the onset of the myocardial infarction. The patient successfully underwent elective repair surgery, after optimizing the medical therapy and completing the necessary workup.

DISCUSSION

Ventricular septal rupture repair is necessary in all cases due to the high mortality rate if left untreated. The timing of the operation, however, should be decided individually for every patient. Haemodynamically unstable patients may require early surgery, but in stable patients responding to medical treatment, delayed repair may be the best option.

Current trends in neonatal ECMO

Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with respiratory and cardiac failure refractory to maximal medical management. The extracorporeal life support organization registry is the largest available resource for describing the population and outcomes of patients treated with this therapy. The use of ECMO for neonatal patients is decreasing in proportion to the total annual ECMO runs most likely due to advancements in medical management. Although the overall survival for neonatal ECMO has decreased, this is likely a reflection of the increasingly complex neonatal patients treated with this therapy. Although many patient and mechanical complications are decreasing over time, there remains a high percentage of morbidities and risks associated with ECMO. Continued refinements in management strategies are important to improving overall patient outcomes.

Different types of mechanical complications after surgical correction of adult spine deformity with osteotomy

AIM

To determine the incidence and risk factors for mechanical complications (MC) after surgical correction of adult spinal deformity (ASD) with osteotomy.

METHODS

A retrospective study was performed. Inclusion criteria: Surgical correction of ASD using osteotomy; male or female; > 20 years old; follow-up ≥ 24 mo or revision. The MC of spine and spinal instrumentation were studied separately. Risk analysis included assessment of the association between more than 50 different characteristics (demographic, clinical, radiographic, and instrumentation) with different types of MC.

RESULTS

The medical records of 94 operations in 88 subjects were analyzed: Female (68%), mean age 58.6 (SD, 12.7) years. Cumulative incidence of MC at 2 year follow-up was 43.6%. Of these, 78% required revision (P < 0.001). The following characteristics had significant (P ≤ 0.05) association with MC: (1) Preoperative: osteoporosis, smoking, previous spinal operation, sagittal vertical axis (SVA) > 100 mm, lumbar lordosis (LL) < 34°; (2) postoperative: SVA > 75 mm; operative correction: SVA > 75 mm, LL > 30°, thoracic kyphosis > 25°, and pelvic tilt > 9°; a fall; pseudarthrosis; and (3) device and surgical technique: use of previously implanted instrumentation; use of domino and/or parallel connectors; type of osteotomy (PSO vs SPO) if preoperative SVA < 100 mm; lumbar osteotomy location; in-situ rod contouring > 60°; and fixation to sacrum/pelvis.

CONCLUSION

Risk of MC after surgical correction of ASD is substantial. To decrease this risk over- and/or insufficient correction of the sagittal imbalance should be avoided.

Mechanical complications of central venous catheterisation in trauma patients

INTRODUCTION Central venous catheterisation (CVC) is a commonly performed procedure in a wide variety of hospital settings and is associated with appreciable morbidity. There is a paucity of literature focusing on mechanical complications specifically in the trauma setting. The aim of our study was to determine the spectrum of mechanical complications in a high-volume trauma centre in a developing world setting where ultrasound guidance was not available. METHODS A retrospective study was performed analysing data from a four-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. RESULTS A total of 178 mechanical complications (18%) occurred in 1,015 patients undergoing CVC: 117 pneumothoraces, 25 malpositions, 18 catheter dislodgements, 14 arterial cannulations, one air embolism, one chylothorax, one pleural cannulation and one retained guide-wire. The internal jugular vein (IJV) approach was associated with a higher overall complication rate than the subclavian vein (SCV) approach (24% vs. 13%, p<0.001). Pneumothorax (73% vs. 57%, p<0.001) and arterial cannulation (15% vs. 0%, p<0.001) were more common with the IJV. Catheter dislodgement (21% vs. 0%, p<0.001) was more common with the SCV. Junior doctors performed 66% of the CVCs and this was associated with a significantly higher complication rate (20% vs. 12%, p<0.001). CONCLUSIONS CVC carries appreciable morbidity, with pneumothorax being the most frequent mechanical complication. The SCV was the most commonly used approach at our institution. The majority of CVCs were performed by junior doctors and this was associated with a considerable complication rate.

Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service

INTRODUCTION This audit of traumatic diaphram injury (TDI) from a busy South African trauma service reviews the spectrum of disease and highlights current approaches to these injuries. METHODS The Pietermaritzburg Metropolitan Trauma Service (PMTS) has maintained an Electronic Surgical Registry (ESR) and a Hybrid Electronic Medical Record (HEMR) system since January 1st 2012. RESULTS A total of 105 TDIs were identified and repaired during the study period. The mean patient age was 30 years (range 15-68 years - SD 9.7). The majority (92.4%) of patients were male (97/105). Penetrating trauma was the leading mechanism of injury (94%). 75 patients sustained a TDI from a stab wound, and the remaining 24 injuries resulted from gunshot wounds. Multiple associated injuries and high morbidity was seen with right diaphragm injury, blunt trauma, gunshot wounds and chronic diaphragmatic hernias. CONCLUSIONS TDI is a fairly uncommon injury with a local incidence of 1.6%. It presents in a spectrum from the obvious to the occult. Multiple associated injuries and high morbidity occur following blunt trauma or gunshot wounds, right diaphragm injury and chronic diaphragmatic hernias. Diagnostic laparoscopy offers a diagnostic and therapeutic tool to prevent progression of occult TDI to chronic diaphragmatic hernias.

Triple cardiac rupture

Left ventricular free wall rupture and acute ischaemic mitral regurgitation are nowadays rare, but still potentially lethal mechanical complications after acute myocardial infarction. We report a case of a sequential left ventricular free wall rupture, anterolateral papillary muscle disruption, secondary severe mitral regurgitation and subsequent posteromedial papillary muscle head rupture in a single patient during the same ischaemic episode after myocardial infarction, and their related successful surgical procedures and management until discharge. Prompt bedside diagnosis and emergent consecutive surgical procedures, as well as temporary left ventricular assistance, were crucial in the survival of this patient.