Ann Thorac Surg 1998;66:1814-1816
© 1998 The Society of Thoracic Surgeons
Case Report
Blunt injury rupture of tricuspid valve and right coronary artery
Timothy H. Trotter, MDa,
Christopher J. Knott-Craig, MDa,
Kent E. Ward, MDb
a Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
b Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
Accepted for publication May 2, 1998.
Address reprint requests to Dr Knott-Craig, Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190
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Abstract
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Successful surgical repair of an unusual case of blunt trauma to the chest and abdomen is presented. The injury resulted in rupture of the pericardium, avulsion and rupture of the right coronary artery into the right atrium, complete disruption of the tricuspid valve, and acute right heart failure with complete heart block.
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Introduction
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In September 1997, a 15-year-old boy was involved in a motorcycle accident during which the victim struck a gate at high speed. He was noted to have a contusion of his anterior chest, complete right bundle-branch block on an electrocardiogram, and a widened cardiac silhouette on a chest radiograph. Other than a laceration on his knee, his clinical findings were unremarkable and his vital signs were stable. He was transferred to our institution 3 hours later; on examination he now had a grade III/VI continuous murmur over the base of the heart and a hyperdynamic precordium. Over the next 5 hours increasing resting dyspnea developed, requiring a transvenous pacemaker. Urgent echocardiography and cardiac catheterization identified what appeared to be a traumatic aortic–right atrial fistula (pulmonary-to-systemic flow ratio >2:1) and severe tricuspid regurgitation (Fig 1). Computed tomographic scan of the abdomen revealed the presence of fluid in Morrison’s pouch as well as a moderate-sized right pleural effusion.
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Fig 1. Cineangiogram showing an apparent traumatic sinus of Valsalva aneurysm into the right atrium. This was in fact a traumatic avulsion of the ostium of the right coronary artery.
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The patient was taken to the operating room emergently and expeditiously placed on cardiopulmonary bypass. His vital signs had rapidly deteriorated, his blood pressure was 70/40 mm Hg, and the central venous pressure was 29 mm Hg. The following cardiac injuries were found: (1) wide rupture of the pericardium into the right pleural space with approximately 400 mL of hemothorax, (2) avulsion of the right coronary artery from its ostium in the sinus of Valsalva (a probe passed easily from the stellate tear marking the RCA ostium into both the right atrium and the right ventricle), (3) complete disruption of the tricuspid valve annulus involving both the anterior and septal leaflets, and (4) a 2- to 3-cm rent in the tricuspid valve annulus at the commissure between the septal and anterior leaflets extending to both the interventricular septum and to the coronary sinus (Fig 2). In the roof of this tear the ragged edges of the disrupted portion of the right coronary artery could be seen.
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Fig 2. Surgeon’s view of the injuries through the opened right atrium. The lacerated right coronary artery is seen in the roof of the right atrium, associated with disruption of the tricuspid valve and annulus.
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Repair involved (1) closure of the aortic orifice of the right coronary with 5-0 Prolene (Ethicon, Somerville, NJ) pledgeted sutures, (2) closure of the lacerations in the right atrium and right ventricle with a glutaraldehyde-tanned pericardial patch, (3) replacement of the tricuspid valve with a 29-mm Carpentier-Edwards bioprosthesis, (4) closure of the disrupted right coronary artery and placement of a saphenous vein aortocoronary bypass graft to the distal right coronary artery, and (5) exploratory laparotomy.
Epicardial pacing wires were placed and the patient was separated from bypass receiving 5 µg · kg-1 · min-1 of dopamine with good hemodynamics. He was extubated the following day, and sinus rhythm spontaneously returned 24 hours later. He made a full recovery and was discharged from the hospital on postoperative day 6. Follow-up electrocardiography and echocardiography 2 months later showed normal biventricular function without any residual defects.
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Comment
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The literature is replete with references to cardiac injuries sustained as the result of blunt thoracic trauma. Tricuspid insufficiency, however, is an unusual event that has resulted in only case reports and an occasional review of the literature [1, 2]. Posttraumatic tricuspid insufficiency is a lesion characterized by chronicity, and most reports deal with patients months to years after the original injury [1, 2]. Rarely, acute hemodynamic decompensation or associated lesions necessitate emergent operation [3–6]. Several reports have noted the association of papillary muscle rupture with a more acute course of progression of symptoms as compared with patients with only chordal rupture [4–7]. Another association with a more fulminant course is that of any acute left-to-right shunt, in our case a coronary artery-to-right atrial fistula [8–10]. The increased right-sided flows exacerbate the traumatic tricuspid regurgitation, producing more pronounced symptoms. In our case the rapid deterioration in the condition of the patient resulted from the right coronary-to-right atrial traumatic fistula.
Surgical options for the treatment of traumatic tricuspid regurgitation include a variety of repair techniques or valve replacement including the use of autologous pericardium (Table 1). Because of the extent of the disruption in our patient, this was not possible. Tricuspid valve replacement has been used in the more disrupted valves, but considerable debate still exists as to the valve of choice for the tricuspid position. Scully and Armstrong [11] reviewed the use of biologic and mechanical prostheses in the tricuspid position in 60 patients and found no difference in patient survival or valve-related complications at 15 years. Munro and associates [12] found that at 7 years, the freedom from valve thrombosis was 100% for biologic valves and 91% for mechanical valves, and the freedom from reoperation was 93% and 87%, respectively. We favor a bioprosthesis in the tricuspid position even though reoperation is anticipated.
We hypothesize that blunt trauma resulting in rupture of the right coronary artery and disruption of the tricuspid valve in our patient resulted from both an acute craniocaudal deceleration injury and a compression injury to the chest with the patient holding his breath (compression-Valsalva injury). This would also result in rupture of the pericardium into the right chest.
Most traumatic coronary artery fistulas result from penetrating trauma, although nonpenetrating injuries have rarely been implicated [8–10, 13]. Our patient’s young age, acute electrocardiographic changes, and conduction disturbance dictated emergent repair of this injury, accomplished with aortocoronary bypass grafting with reversed saphenous vein. The severity of the injuries, the need for future reoperation on the tricuspid valve, and severe right heart failure preoperatively argued against the use of the right internal mammary artery in the patient. Recovery of the sinus rhythm was unexpected but has important long-term prognostic significance for the patient.
In conclusion, tricuspid valve disruption and traumatic aortocameral fistulation may initially present with few symptoms, but the clinical condition may rapidly deteriorate as in our patient. An expeditious operation may be lifesaving, and unnecessary delays should be avoided. Cardiac catheterization is usually not necessary if intraoperative echocardiography is available. If cardiac repair is not necessary, the patient should still be closely observed in an intensive care unit until myocardial contusion, arrhythmias, and acute decompensation have been positively excluded.
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References
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Abstract
Introduction
