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Ann Thorac Surg 1998;66:247-248
© 1998 The Society of Thoracic Surgeons

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Case Reports

Traumatic left ventricular aneurysm and tricuspid insufficiency in a child

^a Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, Department of Surgery, Northwestern University Medical School, Chicago, Illinois, USA

Accepted for publication January 27, 1998.

Address reprint requests to Dr Backer, Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, M/C #22, 2300 Children’s Plaza, Chicago, IL 60614

	Abstract

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We describe a rare combination of left ventricular aneurysm and severe tricuspid valve insufficiency in a 9-year-old boy who sustained blunt chest trauma in a motor vehicle accident. The child underwent successful aneurysmorrhaphy and tricuspid valve replacement 9 months after the accident.

	Introduction

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A previously healthy 9-year-old boy sustained blunt chest and abdominal trauma in a high-speed motor vehicle accident while wearing his seat belt in the back seat of a car. He suffered bilateral lung contusions, acute (nonseptic) pancreatitis, and a right femur fracture. An initial limited transthoracic echocardiogram showed mild to moderate left ventricular dysfunction with impaired ventricular septal motion. An electrocardiogram showed evidence of acute inferior wall infarction. Repeat echocardiography 3 weeks later showed continued moderate left ventricular dysfunction and the new development of moderate tricuspid regurgitation. The patient recovered from his injuries and was discharged home. Over the next 6 months he had progressive decrease in exercise tolerance. Repeat echocardiography 8 months after the injury showed moderate to severe left ventricular dysfunction. In addition, a 2.5 x 2.0-cm aneurysm was found in the inferior wall of the left ventricle. Moreover, the tricuspid insufficiency was now severe with flail tricuspid valve leaflets. These findings were all confirmed by cardiac catheterization (Fig 1). Coronary angiography was normal.

View larger version (158K): [in this window] [in a new window]   Fig 1. Cardiac catheterization. Left ventricular contrast injection demonstrates the inferior wall aneurysm.

Echocardiography 8 months after the operation showed significant improvement in left ventricular function, no residual aneurysm, no tricuspid regurgitation, return of the right atrium and right ventricle to normal size, and excellent right ventricular function. The patient is clinically asymptomatic and his only cardiac medication is captopril. The atrioventricular heart block has persisted and he continues using his pacemaker.

	Comment

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The mechanism of cardiac injury from blunt trauma can either be direct compression between the sternum and the vertebral column, or a sudden increase in the intrathoracic pressure from abdominal and lower extremity compression causing a "hydraulic ram effect" [1]. The majority of blunt cardiac injuries are myocardial contusions. Other injuries from blunt trauma include myocardial aneurysm, valvular insufficiency, septal defects, and coronary artery injury.

Most ventricular aneurysms that follow blunt trauma are true aneurysms (wall formed by the scarred myocardium), in contrast to pseudoaneurysms (hematoma from ventricular rupture contained by pericardium) that commonly follow penetrating trauma. The pathogenesis of true aneurysms can be from either transmural myocardial contusion and necrosis or trauma-induced thrombosis of the coronary vessels causing ischemic damage [2]. In our patient the aneurysm appeared to develop over a period of months from a myocardial contusion because coronary angiography was normal. Almost all patients with true aneurysms will have evidence of transmural myocardial infarction and present later with one or more complications—essentially the same as those of ischemic aneurysms—namely, arrhythmias, heart failure, or systemic emboli. Successful repair of a left ventricular aneurysm from blunt trauma was first reported in 1965 [3]. Repair by endoaneurysmorrhaphy with an intracavitary patch is preferable to linear repair and has been shown to result in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome [4]. Our patient had a significant improvement in left ventricular function over a 6-month postoperative follow-up.

Traumatic tricuspid insufficiency from blunt trauma is relatively uncommon. Diagnosis of this lesion has been greatly enhanced by the widespread use of two-dimensional plus color Doppler echocardiography, particularly transesophageal echocardiography [5]. The pathophysiology involves a severe elevation of the right ventricular intracavitary pressure from compression of the full heart in diastole. Chordal rupture is the most frequent cause of tricuspid insufficiency, followed by rupture of the papillary muscles and leaflet tears [6]. Isolated tricuspid regurgitation is often well tolerated for many years without surgical intervention. In van Son and colleagues’ series of 13 cases [7], there was a median duration between the traumatic event and operation of 17 years. Of those 13 patients, 5 had tricuspid valve repair and 8 had tricuspid valve replacement. Van Son and colleagues noted that when the operation was delayed the papillary muscles, chordae tendineae, and involved leaflets were frequently contracted and atrophic, precluding valve repair. If feasible, valve repair as described by Katz and Pallas [8] is preferable to valve replacement. In our patient the absence of identifiable papillary muscles led to an unsuccessful valvuloplasty. Fortunately, tricuspid valve replacement has resulted in complete return of right ventricular function.

	Acknowledgments

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We thank Dr Alexander J. Muster for providing the cardiac catheterization image.

	References

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1. Lasky I.I., Nahum A.M., Siegel A.W. Cardiac injuries incurred by drivers in automobile accidents. J Forensic Sci 1969;14:13-33.[Medline]
2. Silver G.M., Spampinato N., Favaloro R.G., Groves L.K. Ventricular aneurysms and blunt chest trauma. Chest 1973;63:628-631.[Abstract/Free Full Text]
3. Green L., Oakley C.M., Davies D.M., Cleland W.P. Successful repair of left ventricular aneurysm and ventricular septal defect after indirect injury. Lancet 1965;2:984-986.[Medline]
4. Shapira O.M., Davidoff R., Hilkert R.J., Aldea G.S., Fitzgerald C.A., Shemin R.J. Repair of left ventricular aneurysm: long-term results of linear repair versus endoaneurysmorrhaphy. Ann Thorac Surg 1997;63:701-705.[Abstract/Free Full Text]
5. Banning A.P., Durrani A., Pillai R. Rupture of the atrial septum and tricuspid valve after blunt chest trauma. Ann Thorac Surg 1997;64:240-242.[Abstract/Free Full Text]
6. Perlroth M.G., Hazan E., Lecompte Y., Gougne G. Chronic tricuspid regurgitation and bifascicular block due to blunt chest trauma. Am J Med Sci 1986;291:119-125.[Medline]
7. Van Son J.A.M., Danielson G.K., Schaff H.V., Miller F.A. Traumatic tricuspid valve insufficiency: experience in thirteen patients. J Thorac Cardiovasc Surg 1994;108:893-898.[Abstract/Free Full Text]
8. Katz N.M., Pallas R.S. Traumatic rupture of the tricuspid valve: repair by chordal replacement and annuloplasty. J Thorac Cardiovasc Surg 1986;91:310-314.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ramesh S. Veeragandham Carl L. Backer Constantine Mavroudis Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Veeragandham, R. S. Articles by Wilson, A. D. Search for Related Content PubMed PubMed Citation Articles by Veeragandham, R. S. Articles by Wilson, A. D.