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Ann Thorac Surg 2000;69:616-618
© 2000 The Society of Thoracic Surgeons

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Case Reports

Mitral and tricuspid valve rupture after moderate blunt chest trauma

^a Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
^b Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah, USA

Address reprint requests to Dr Bailey, Department of Anesthesiology, University of Rochester Medical Center, 601 Elmwood Ave, Box 604, Rochester, NY 14642
e-mail: peter-bailey{at}urmc.rochester.edu

	Abstract

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We present a patient with rupture of both atrioventricular valves in a previously healthy adult man who sustained a 5-foot fall. The mechanism of injury was such that it would not necessarily raise an adequate index of suspicion for valvular damage had valvular rupture not occurred. The usefulness of perioperative echocardiography is highlighted.

	Introduction

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Trauma, especially involving motorized vehicles, can result in serious multiple injuries. Cardiac and major vessel injuries are known to occur in this setting [1]. It is assumed that the underlying mechanism common to these problems requires a certain amount of force, hence the association between accidents involving motorized vehicles and serious injury. We report a case of rupture of both mitral and tricuspid valves in a previously healthy 41-year-old man who fell 5 feet and sustained blunt chest trauma.

A previously healthy 41-year-old man, 173 cm tall and weighing 88 kg, presented to the emergency room complaining of shortness of breath and chest pain. He fell approximately 5 feet from a library ladder and struck his chest on a bookshelf transversely during the fall. He did not lose consciousness. He was transported emergently to the hospital when he developed acute shortness of breath and pain shortly after his fall. Upon arrival, he was awake and oriented with a heart rate of 120 beats/minute, palpable peripheral pulses, good breath sounds, and an obvious contusion across his lower sternum and left rib cage. No other injuries were found.

Shortly after his arrival, the patient became anxious with increasing shortness of breath, and his condition rapidly deteriorated. Systolic blood pressure decreased to 70 mm Hg, heart rate increased to 130 to 140 beats/minute, and peripheral pulse oximetry indicated significant oxyhemoglobin desaturation. Chest radiography revealed a large globular heart and a fractured left rib. The patient had his trachea intubated and copious frothy edema fluid was evident. Repeat chest roentgenogram revealed florid bilateral pulmonary edema. The patient continued to deteriorate (frequent premature ventricular contractions, systolic blood pressure about 50 mm Hg, pulse oximeter about 60%). A presumptive diagnosis of acute cardiac tamponade was made. Because of the immediately life-threatening nature of the patient’s problem, a left anterior thoracotomy was performed in the emergency room. Only 20 mL of blood was evacuated during pericardiocentesis. The heart was noted to be quite full.

Transthoracic echocardiography in the emergency room revealed a flail mitral valve (MV). The patient continued to be very hemodynamically unstable, requiring multiple doses of epinephrine. He was taken to the operating room for emergent open heart operation. Confirmation of the diagnosis of flail mitral valve was made with transesophageal echocardiography immediately before cardiopulmonary bypass (Fig 1).

View larger version (54K): [in this window] [in a new window]   Fig 1. Transesophageal echocardiograph revealing a flail mitral valve. The ruptured anterior papillary muscle can be seen in the left atrium.

Upon weaning and separation from cardiopulmonary bypass, transesophageal echocardiographic examination by the anesthesiologist revealed severe tricuspid valve regurgitation (Fig 2). After reinstituting cardiopulmonary bypass, the right atrium was opened and inspection of the tricuspid valve revealed a ruptured anterior papillary muscle. The tricuspid valve was excised and a 31-mm St. Jude prosthetic valve placed in its position. The sternal and rib fractures were repaired, and all surgical wounds closed.

View larger version (67K): [in this window] [in a new window]   Fig 2. Transesophageal and color flow Doppler study revealing severe tricuspid regurgitation. In the center of the image is the aortic valve annulus; above is the left atrium and below, the right ventricle.

	Comment

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This is the third single case report of rupture of both atrioventricular valves associated with trauma, with one report being part of an autopsy series [1, 2]. It is a report of such an injury after apparent moderate trauma. Although cardiac valvular injuries are relatively uncommon after trauma, valvular or other cardiac damage has been consistently reported after severe trauma [3, 4]. The tricuspid valve is perhaps particularly vulnerable because the right ventricle is immediately behind the sternum [4]. Other reports make it unclear as to whether any particular cardiac valve is most prone to injury from trauma [5].

The purported mechanism of injury is compression of the heart during late diastole or isovolemic systole [5]. At this time the cardiac chambers are full and the valves are closing or closed. Acute, significant thoracic compression transmits pressure, and likely leads to severe atrioventricular valve prolapse and rupture. Damage or disruption at the chordal or papillary muscle level is typical [3, 4].

The present case report highlights several points. First, it emphasizes that significant cardiac injury can occur even with what appears to be moderate blunt thoracic trauma. Although other mechanisms of injury besides motor vehicle accidents can result in cardiac damage, these have to date consisted of similarly severe traumas, such as falls from one or more stories, falls off a horse or bus [5, 6], and compressed air explosions [7].

Second, if delays in the correct diagnosis of cardiac and cardiac valvular injury or injuries are to be avoided, perhaps a higher index of suspicion is required when patients present with a history of only moderate blunt chest trauma. Multiple injuries should be suspected. Initially we overlooked the possibility of tricuspid valve rupture because mitral valve rupture was sufficient to explain our patient’s condition.

Finally, although the application of intraoperative transesophageal echocardiography by anesthesiologists is progressing, it remains controversial and difficult to achieve as a standard of care. Nevertheless, the current case highlights how the intraoperative use of transesophageal echocardiography can yield unpredictable benefit. Without transesophageal echocardiography, the immediate diagnosis of severe tricuspid valve regurgitation might not have been made.

	References

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1. Parmley L.F., Manion W.C., Mattingly T.W. Nonpenetrating traumatic injury of the heart. Circulation 1958;18:371-396.[Medline]
2. Pellegrini R.V., Copeland C.E., DiMarco R.F., et al. Blunt rupture of both atrioventricular valves. Ann Thorac Surg 1986;42:471-472.[Abstract]
3. 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]
4. 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]
5. Cuadros C.L., Hutchinson J.E., Mogtader A.H. Laceration of a mitral papillary muscle and the aortic root as a result of blunt trauma to the chest. Case report and review of the literature. J Thorac Cardiovasc Surg 1984;88:134-140.[Abstract]
6. Gay J.A., Gottdiener J.S., Gomes M.N., Patterson R.H., Fletcher R.D. Echocardiographic features of traumatic disruption of the aortic valve. Chest 1983;83:150-151.[Abstract/Free Full Text]
7. Van Son J.A., 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]

This article has been cited by other articles:

				J.-S. Choi and E.-J. Kim Simultaneous Rupture of the Mitral and Tricuspid Valves With Left Ventricular Rupture Caused by Blunt Trauma Ann. Thorac. Surg., October 1, 2008; 86(4): 1371 - 1373. [Abstract] [Full Text] [PDF]

				M. P. Petkov, C. A. Napolitano, H. G. Tobler, T. J. Ferrer, J. M. Palacios, and M. D. Wangler A Rupture of Both Atrioventricular Valves After Blunt Chest Trauma: The Usefulness of Transesophageal Echocardiography for a Life-Saving Diagnosis Anesth. Analg., May 1, 2005; 100(5): 1256 - 1258. [Abstract] [Full Text] [PDF]

				D. G. Karalis, B. J. Tortella, and K. Chandrasekaran Role of Transesophageal Echocardiography in Blunt Chest Trauma Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2002; 6(2): 149 - 163. [Abstract] [PDF]

				B. M. RuDusky and G. Cimochowski Traumatic Tricuspid Insufficiency: A Case Report Angiology, March 1, 2002; 53(2): 229 - 233. [Abstract] [PDF]

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): Shreekanth V. Karwande Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bailey, P. L. Articles by Lapunzina, P. Search for Related Content PubMed PubMed Citation Articles by Bailey, P. L. Articles by Lapunzina, P.