Surgical Management for Traumatic Septal Rupture in a Child With Cardiogenic Shock

A 12-year-old boy had a blunt chest trauma in a motor vehicle accident. He arrested on arrival to the hospital and underwent clamshell thoracotomy for bilateral haemothorax. He required direct cardiac massage and massive transfusion for chest wall bleeding and pulmonary haemorrhage. Computerised tomography revealed a large apical ventricular septal defect (VSD) (Figure 1A). He developed cardiogenic shock with blood pressure 65/50 mmHg, central venous pressure 15 mmHg and lactate of 24 mmol/L, despite adrenaline/noradrenaline at 1.5 mcg/kg/min and vasopressin at 0.06 units/kg/hr. He was emergently cannulated for central extracorporeal membrane oxygenation (ECMO) and epicardial echocardiography confirmed a large VSD (Figure 1B). He was transferred to theatre and ECMO was switched to cardiopulmonary bypass. Emergent VSD closure was performed with cardioplegic arrest via right ventriculotomy (Figure 1C). A pericardial patch was oversized and secured on the left ventricular (LV) side with four sutures and a running suture (Figure 1D), so that the patch could reliably seal the hole in the ruptured septum with fragile edges. The ventriculotomy was then closed between two felt strips (Figure 1E). Postoperatively, there were no myocardial contractions, despite normal sinus rhythm, likely due to tachyphylaxis because of high preoperative catecholamine doses. Thus, the LV was drained with apical venting to prevent pulmonary congestion. The patient remained on ECMO support for 14 days. He also developed rhabdomyolysis with a creatine kinase of 71,000 units/L and myoglobin of 59 mg/L, contributing to acute renal failure. His cardiac function normalised after one month. He temporarily required a tracheostomy and haemodialysis, but recovered with normal respiratory and renal function and without any neurological sequelae.