Left ventricular-right atrial communication with third-degree atrioventricular block after thoracic trauma.

BACKGROUND: Intracardiac shunts are rare but very serious lesions after non-penetrating chest trauma. Their diagnosis is difficult. This pathology often goes unrecognized in the context of multiple trauma. CASE REPORT: We report the case of a 21-year-old man involved in a motor vehicle crash who presented with multiple injuries including myocardial contusion, severe brain injury, multiple pelvic fractures, closed femur fracture, bilateral lung contusion with a right pneumothorax, and intra-abdominal injuries. Three days after the initial event, a new cardiac murmur and complete heart block appeared. Transthoracic echocardiography (echo) followed by transesophageal echo revealed a high-velocity flow communication between the left ventricle and the right atrium. The patient underwent delayed cardiac surgery due to other unstable injuries. The hospital course was prolonged but favorable, and the patient left the hospital 1 month later without any neurologic or cardiologic after-effect. CONCLUSION: This case highlights the potential for cardiac complications to occur in any patient with serious thoracic trauma. Transesophageal echo should be performed on any trauma patient with electrocardiographic abnormalities.

Cardiovascular effects of low-dose spinal anaesthesia as a function of age: An observational study using echocardiography.

BACKGROUND: Spinal anaesthesia (SA) is a widely used technique of regional anaesthesia but hypotension is an adverse effect commonly observed, especially in elderly patients. OBJECTIVE: The objective of this study was to assess the cardiovascular effects induced by a single injection of a low-dose SA during elective surgery by using transthoracic echocardiography (TTE) and to compare these effects in patients older and younger than 70 years of age. DESIGN: Observational study. SETTING: Single centre university hospital. PATIENTS OR OTHER PARTICIPANTS: Forty-six patients scheduled for surgery under SA were included in the study (25 patients<70 years and 21 patients ≥ 70 years). INTERVENTION(S): A cardiologist, blinded to all clinical parameters, interpreted the TTE. MAIN OUTCOME MEASURES: Two TTEs were performed for each patient: one at baseline before and the second 20 minutes after the placement of the SA. RESULTS: Sixty-six percent of patients became hypotensive in the ≥ 70 years group whereas no episode of hypotension occurred in the<70 years group (P<0.0001). At baseline (i.e. prior to SA), when compared to younger patients, elderly patients had both a lower E/A ratio (0.8 [0.5-2.1] vs. 1.4 [0.7-1.6], P=0.001) as well as a lower LVEF (50.4% [37.7-72.3] vs. 60.9% [44.8-69.8], P<0.0001). SA in the elderly induced a larger decrease in the cardiac index (CI) (-0.5 L·min(-1)·m(-2) [-0.8 to -0.3] vs. -0.2 L·min(-1)·m(-2) [-0.8-0.1], P<0.0001), LV stroke volume (-8mL [-13-4] vs. -2mL [-14 to -1], P<0.0001) and systemic vascular resistances (SVR) (-2.2 WU [-6.7-0.3] vs. -0.8 WU [-2.3-0.1], P<0.0001). CONCLUSIONS: Hypotension is more frequent among elderly patients, even after low-dose SA. Known age-related changes in cardiovascular performance, such as impaired myocardial relaxation and decreased systolic function could be responsible for the decrease in cardiac output (CO) and SVR seen in these patients.