Ann Thorac Surg 2000;69:1251-1253
© 2000 The Society of Thoracic Surgeons
CASE REPORTS
Repair of traumatic aortic valve disruption and descending aortic transection
Leonard Girardi, MDa,
O. Wayne Isom, MDa
a Department of Cardiothoracic Surgery, The New York Hospital-Cornell Medical Center, New York, New York, USA
Address reprint requests to Dr Girardi, Department of Cardiothoracic Surgery, The New York Hospital-Cornell Medical Center, 525 E 68th St, F-2103, New York, NY 10021
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Abstract
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Traumatic aortic transection after acute deceleration injury remains a highly lethal condition. Concomitant aortic valve disruption is exceedingly rare, and can complicate the timing of surgical management. This report describes the management and outcome of a patient with these types of injuries.
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Introduction
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Traumatic transection of the descending thoracic aorta remains a highly lethal condition. Approximately 80% of patients incurring this injury die at the scene of the accident, while an additional 15% expire during resuscitation or treatment. Disruption of the aortic valve is also a known complication following acute deceleration injuries. Concomitant injury to both the descending thoracic aorta and the aortic valve is rare. A successful outcome is dependent not only on a technically sound repair, but also on the correct decision as to which lesion requires more urgent intervention. Intensive manipulation of the patients’ hemodynamic status is paramount in the interval between repairs to improve the chance of survival.
A 73-year-old man with a history of hypertension fell approximately 25 feet from his roof onto his left side. He remained neurologically intact, and was transported to a local hospital with stable hemodynamics. On physical exam he had diminished breath sounds on the left and a benign abdominal exam. Closed fractures of the left humerus and left fibula were noted without evidence of distal vascular compromise. Cardiac exam was unremarkable and the patient had an oxygen saturation of 100%. Chest roentgenogram was notable for fifth and sixth posterior left rib fractures and a moderate pneumothorax. There was no mediastinal widening, pleural cap or hemothorax. A left thoracostomy tube was inserted without complication. The remainder of his radiographic examination, including a computed tomographic scan of his head, was without evidence of injury. He was admitted to the intensive care unit for monitoring.
The following morning the patient became hypoxemic. A new, III/VI diastolic murmur was noted. Chest roentgenogram was consistent with acute pulmonary edema. The hematocrit was stable and his chest tube was without bloody drainage. Cardiac enzymes were negative and he had no new arrhythmias. Mechanical ventilation was instituted and a transesophageal echocardiogram (TEE) was performed. TEE revealed severe aortic insufficiency (AI) with disruption of his noncoronary aortic leaflet (Fig 1). Ventricular function was normal with no segmental wall motion abnormalities. There was no pericardial effusion. Examination of the aorta revealed a mediastinal hematoma adjacent to the distal aortic arch with intimal disruption and flow into the hematoma (Fig 2). He was transferred to our hospital for definitive management.
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Fig 1. Transesophageal echocardiogram demonstrating a tear (arrow) in the noncoronary leaflet of the aortic valve. Color-flow Doppler revealed severe aortic insufficiency (Ao = ascending aorta, LA = left atrium).
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Fig 2. Transesophageal echocardiogram demonstrating a mediastinal hematoma (MH) adjacent to the medial wall (arrow) of the proximal descending thoracic aorta (Ao). Color-flow Doppler confirmed flow through the aortic wall into this hematoma.
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Urgent cardiac catheterization with aortography confirmed severe AI and a traumatic aortic transection at the ligamentum arteriosum. Because of severe AI and pulmonary edema, aortic valve replacement was performed first. On cardiopulmonary bypass the aortic valve was examined. There was complete separation of the base of the noncoronary leaflet from the aortic annulus. The remaining leaflets were normal and there was no evidence of an ascending aortic injury. A 21-mm bovine pericardial valve (Baxter Healthcare, Irvine, CA) was implanted without complication. The patient was extubated on postoperative day 2 without evidence of neurologic injury. Aggressive diuresis was initiated, and he was kept in the intensive care unit on aggressive ß-blockade and afterload reduction.
On postoperative day 6, he was returned to the operating room for repair of his aortic transection. Utilizing left atrial to femoral artery partial bypass, the aortic transection was repaired with a 26-mm Dacron (C. R. Bard, Haverhill, PA) graft. Aortic cross-clamp time was 26 minutes. The patient awakened neurologically intact and was extubated on postoperative day 1. He was transferred out of intensive care and discharged to rehabilitation on postoperative day 10. He remains well 6 months later.
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Comment
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Blunt disruption of the descending thoracic aorta is not uncommon in high-speed deceleration accidents [1]. The mortality associated with this lesion remains high, with 80% of patients succumbing to injury in the field and another 15% expiring in the hospital. Traumatic disruption of the aortic valve is much less common. Initially described in 1830 [2], aortic valve injury occurs as severe increases in intrathoracic pressure are transmitted across the closed valve during early diastole. Before the creation of reliable aortic valve prostheses, aortic valve repair was the technique of choice for traumatic aortic insufficiency [3]. However, long-term results with primary repair have been disappointing [4]. A reliable result has been obtained with prosthetic aortic valve replacement, and this method is currently the procedure of choice[5, 6].
Simultaneous injury to the aortic valve and descending thoracic aorta has been reported once previously [7]. The critical issue is the appropriate timing of surgical intervention for concurrent injuries. Intraabdominal injuries with ongoing hemorrhage require immediate attention. During laparotomy, patients with new murmurs or with radiography suggestive of aortic injury may benefit from evaluation with TEE [8]. The effectiveness of TEE in assessing aortic valve and descending aortic pathology is superb. Greater experience with TEE in this patient population may eventually obviate the need for invasive diagnostic procedures. Patients, who are hemodynamically stable despite acute aortic insufficiency, should have their transection corrected first. The use of left-heart bypass during this repair assists in maintaining hemodynamic stability by unloading the heart during a period of aortic cross-clamping. In the setting of florid heart failure, urgent aortic valve replacement may take precedence over repair of the aortic transection.
Medical management of traumatic aortic transection is required in the patient with multiple, life-threatening injuries [9]. Aggressive ß-blockade and afterload reduction can minimize the risk of complete aortic disruption, while severe intraabdominal or intracranial trauma is attended to. The appropriate sequence of surgical repair should be dictated by the patients’ clinical condition.
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References
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Sturm J.T., McGee M.B., Luxenberg M.G. An analysis of risk factors for death at the scene following traumatic aortic rupture. J Trauma 1988;28:1578-1580.[Medline]
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Penderleath D. Case of death from rupture of one of semilunar valves of the aorta. London Medical Gazette 1830;7:109.
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Beall A.C., Shirkey A.L. Successful surgical correction of traumatic aortic valve regurgitation. JAMA 1964;187:507-510.[Medline]
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Pretre R., Faidutti B. Surgical management of aortic valve injury after nonpenetrating trauma. Ann Thorac Surg 1993;56:1426-1431.[Abstract]
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Devineni R., McKenzie F.N. Avulsion of a normal aortic valve cusp due to blunt chest injury. J Trauma 1984;24:910-912.[Medline]
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Munshi I.A., Barie P.S., Hawes A.S., et al. Diagnosis and management of acute aortic valvular disruption secondary to rapid-deceleration trauma. J Trauma 1996;41:1047-1050.[Medline]
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Paone R.F., Kidd J.N., Dobrin D.J., et al. Traumatic aortic incompetence associated with transection of the thoracic aorta. Chest 1996;109:1118-1119.[Abstract/Free Full Text]
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Shapiro M.J., Yanofsky S.D., Trapp J., et al. Cardiovascular evaluation of blunt thoracic trauma using transesophageal echocardiography. J Trauma 1991;31:835-840.[Medline]
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Pate J.W., Gavant M.L., Weiman D.S., Fabian T.C. Traumatic rupture of the aortic isthmus. World J Surg 1999;23:59-63.[Medline]
Accepted for publication August 4, 1999.
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Abstract
Introduction
