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Ann Thorac Surg 1997;64:240-242
© 1997 The Society of Thoracic Surgeons

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Case Report

Rupture of the Atrial Septum and Tricuspid Valve After Blunt Chest Trauma

Departments of Cardiology and Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, England

Accepted for publication February 15, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
A previously fit 19-year-old male driver was involved in an unrestrained, head-on collision. Transesophageal echocardiography revealed rupture of the chordae subtending both leaflets of the tricuspid valve with severe tricuspid regurgitation and disruption of the interatrial septum. When cardiac injury is suspected after blunt chest trauma, transesophageal echocardiography facilitates appropriate management as it provides safe, rapid, and accurate diagnostic images.

	Introduction

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A previously fit 19-year-old male driver was involved in a high-speed, unrestrained, head-on collision. After recovery from the car, the patient collapsed and he was intubated and resuscitated according to a standard protocol.

On arrival in the hospital he was tachycardic, hypotensive and hypoxic despite ventilation with 100% oxygen. Bruising and distention of the abdomen was noted. A portable chest radiograph suggested cardiomegaly with possible widening of the mediastinum. The electrocardiogram demonstrated right bundle-branch block with marked inferior and septal ST abnormality (Fig 1). Aortography was normal but computed tomography revealed rupture of the left lobe of the liver. This liver laceration was repaired surgically and the wound was packed.

View larger version (127K): [in this window] [in a new window]   Fig 1. . Twelve-lead electrocardiogram recorded on arrival in hospital demonstrating multifocal ventricular ectopics, right bundle-branch block, and marked ST segment abnormality.

View larger version (52K): [in this window] [in a new window]   Fig 2. . Transverse-plane, two-dimensional transesophageal echocardiographic cardiac image during ventricular systole (A) and artist's impression of the echocardiogram (B). The septum between the left atrium (LA) and the right atrium (RA) is disrupted, and the tricuspid valve is completely everted with remnants of the subvalvar apparatus (white arrow) prolapsing into the RA. (RV = right ventricle.)

His postoperative recovery was complicated by complete heart block and hypotension. A balloon pump and transvenous atrioventricular sequential pacing wires were inserted and he received inotropic support. Transesophageal echocardiography revealed significant impairment of global right ventricular function, but no tricuspid regurgitation and no residual right-to-left intracardiac shunt. He improved progressively and was extubated 10 days postoperatively. His subsequent mobilization was slow, but with intensive physiotherapy he made a complete recovery and he was discharged home 5 weeks after the accident.

	Comment

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When cardiac injury is suspected after blunt chest trauma, transesophageal echocardiography is the diagnostic imaging modality of choice as it is safe and rapid and provides high-quality diagnostic images [1]. Ventricular contusion is the most common cardiac injury, but free wall rupture, septal rupture, and valvular disruption have all previously been described [2]. The frequency of the types of cardiac injury reflects the mechanism of trauma and the cardiac anatomy.

The right ventricle is immediately behind the sternum, and this predisposes it to injury [2]. After blunt chest trauma, contusion of the right ventricle occurs in approximately 20% of patients [1], and acutely, this may be associated with falls in cardiac output of up to 33% [3]. Despite this, recovery of systolic function is usually complete and survivors usually have no long-term sequelae [4].

The right ventricle is also susceptible to indirect crush injuries as compression of the upper abdomen and limbs can result in massive increases in hydraulic pressure with a resultant increase in intracardiac pressure. The combination of cardiac and liver trauma in this case suggests that impact occurred during isovolumic contraction of the right ventricle and that catastrophic increases in intracardiac pressure resulted in concomitant rupture of the tricuspid valve and the atrial septum.

Rupture of the tricuspid valve is uncommon after blunt trauma, but as the defect is often well tolerated, its frequency may be underestimated. A recent review of 13 cases demonstrated a median duration between trauma and operation of 17 years with a postoperative median survival of 12 years [5].

Right-to-left intracardiac shunting has been described previously after traumatic rupture of the tricuspid valve [6], but the intracardiac shunt in those cases was through a patent foramen ovale, and the onset of symptoms was gradual. Traumatic injury to the atrial septum is very unusual [2]. Emergency operation was undertaken in our case after the failure of conservative management and in the presence of refractory hypotension and hypoxia. As tricuspid valve repair was not possible, a bioprosthesis was inserted to avoid the requirement for early postoperative anticoagulation and to facilitate transvenous cardiac pacing.

	Footnotes

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Address reprint requests to Dr Banning, Department of Cardiology, John Radcliffe Hospital, Oxford, OX3 9DU, England.

	References

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1. Weiss RL, Brier JA, O'Conner W, Ross S, Braithwaite CM. The usefulness of transesophageal echocardiography in diagnosing cardiac contusions. Chest 1996;109:73–7.[Abstract/Free Full Text]
2. Kulshrestha P, Das B, Iyer KS, et al. Cardiac injuries-a clinical and autopsy profile. J Trauma 1990;30:203–7.[Medline]
3. Diebel LN, Tagget MG, Wilson RF. Right ventricular response after myocardial contusion and hemorrhagic shock. Surgery 1993;114:788–93.[Medline]
4. Struraitis M, McCallum D, Sutherland G, Cheung H, Dreidger AA, Sibbald WJ. Lack of significant long term sequelae following traumatic myocardial contusion. Arch Intern Med 1986;146:1765–9.[Abstract]
5. Van Son JAM, Danielson GK, Schaff HV, Miller FA. Traumatic tricuspid valve insufficiency-experience in thirteen patients. J Thorac Cardiovasc Surg 1994;108:893–8.[Abstract/Free Full Text]
6. Ribichini F, Conte R, Lioi A, Dellavalle A, Ugliengo G. Subacute tricuspid regurgitation with severe hypoxemia complicating blunt chest trauma. Chest 1996;109:289–91.[Abstract/Free Full Text]

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