Ventricular septal defect caused by impact from a horseshoe

Clinical Summary A 116-year-old woman came to the emergency department 36 hours after a closed thoracic trauma that had occurred when she was dropped from her horse and then was trodden on by her horse. Acute dyspnea and concomitant hemoptysis were her reasons for seeking treatment. Physical examination showed a pulse of 130 beats/min and blood pressure of 95/45 mm Hg, paleness, and erosions over the skin in the image of a horseshoe. The heart had a normal S1 and S2 sounds and grade 6/6 holosystolic murmur at the left bottom sternal border irradiating to the right bottom sternal border. There was bibasal hypoventilation with a tubaric murmur on the right thorax. Electrocardiography demonstrated elevation of the ST segment in the right leads. Biochemical testing showed a hemoglobin level of 10.3 g/dL, total creatine kinase of 222 IU/L, MB isoenzyme of creatine kinase of 7.8 (index 3.5%), and cardiac troponin I level of 13.10 ng/mL. Chest radiography (Figure 1) showed a normal cardiac size, Kerley B lines, pulmonary congestion, and bilateral pleural effusion. Computed tomographic scan showed multiple rib fractures, pulmonary contusion, and pericardial effusion. These data were compatible with a ventricular septal defect. An echocardiogram was therefore performed (Figure 2). On transthoracic apical 4-chamber view, the ventricles appeared dilated and dysfunctional and demonstrated a ventricular septal