Emergency Closure of a Traumatic Ventricular Septal Defect (VSD) after a Horse Kick Injury with an 18-mm Occlutech ASD Occluder

Objective: Thoracic injuries after accidents with horses include chest lung contusions, rib fractures, and rarely cardiac involvement including right heart perforation, avulsion of the tricuspid or mitral valve and aortic dissections. We report a unique case of a traumatic ventricular septal defect.

Case Report: A 25-year-old woman was kicked to the left chest by a large horse (Haflinger). She was transferred to a trauma center in stable condition and spontaneously breathing where aortic dissection, rib fractures and cardiac perforation were ruled out by a chest CT and mild pulmonary contusion was diagnosed. Subsequently a murmur developed and the patient deteriorated hemodynamically. After transfer to our center 18 hour after injury she presented in pulmonary edema, low cardiac output and multiorgan failure, requiring ventilation with PEEP 12, FiO₂ of 1,0, and catecholamine support. TTE revealed a large muscular VSD with areas of surrounding intramuscular hematoma. Hemodynamic assessment revealed a dramatic shunt (calculated QP/QS > 8:1, CI < 2 l/min/m²) and TEE and angiography confirmed the large VSD (10 × 14 mm) with intramural hematoma and surrounding areas of splatted and frayed musculature protruding in the left ventricle. We implanted an 18 mm Occlutech ASD occluder to cover the large areas of fibers protruding into the left side and thereby covering the VSD and aligning the septum. Intraprocedural TEE confirmed the adequate position of the device with significant reduction of shunt. The patient was transferred back to the ICU where she required a period of ventilation with iNO, renal replacement therapy and catecholamine support to recover from pulmonary edema and multiorgan failure. She was extubated 7 days later and discharged 17 days after the injury. A control MRI and ECHO before discharge showed accurate position of the device, and a residual shunt of less than 2:1 with normal pressures in the right ventricle.

Conclusion: This is a rare case of a traumatic VSD caused by a horse-kick injury. This trauma induced significant intramuscular hematoma and secondary perforation. Based on the anatomy the use of an ASD occluder enabled an adequate shunt reduction and recovery of the patient.