An unusual intracardiac shunt secondary to penetrating cardiac trauma.

A 22 year old man was admitted to the accident and emergency department having sustained a 5 × 3 cm knife wound to the right anterior chest wall in the fourth intercostal space. He was haemodynamically stable on admission but dyspnoeic at rest. Pulse was 110 beats/min and blood pressure 106/60 mm Hg. The only abnormality on examination was dullness to percussion on the right chest wall; heart sounds were normal. A plain chest x ray confirmed a right haemothorax. Three litres of blood were drained using an intercostal drain. A median sternotomy was performed; the right internal thoracic artery, which had been transected,was ligated. A small laceration in the right atrioventricular groove was sutured. The patient made an unremarkable recovery and was discharged home. He was reviewed three weeks later when examination revealed a pansystolic murmur over the whole precordium. A transthoracic echocardiogram showed a high velocity jet from the left ventricle to the right atrium. Transoesophageal echocardiography at a depth of 30 cm and in multiple planes demonstrated a laceration in the junction of the aortomitral continuity and the intra-atrial septum (figs 1 and 2). Colour flow mapping confirmed high velocity flow from the left ventricular outflow tract to right and left atria. He has remained well over the past 12 months and has been managed conservatively with regular follow up and advice about prophylactic antibiotics.