Ann Thorac Surg 2000;70:1692-1694
© 2000 The Society of Thoracic Surgeons
Case report
Multiple intracardiac lesions after blunt chest trauma
Alejandro Aris, MD, PhDa,b,
Luis Javier Delgado, MDa,b,
José Montiel, MDa,b,
Maria Teresa Subirana, MDa,b
a Department of Cardiac Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
b Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
Address reprint requests to Dr Aris, Cardiac Surgery Service, Hospital de la Santa Creu i Sant Pau, San AM Claret 167, 08025 Barcelona, Spain
e-mail: aaris{at}hsp.santpau.es
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Abstract
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Closed chest trauma can cause rupture of intracardiac structures. We report the case of a 17-year-old boy whose chest was trodden by a horse. He sustained rupture of tricuspid and aortic valve leaflets and rupture of the interventricular septum. He underwent surgical repair of these lesions, but aortic insufficiency developed 2 years later and the aortic valve was replaced with a mechanical prosthesis.
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Introduction
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Several intracardiac structures can be affected as a result of non-penetrating chest trauma. We report the case of a young boy who suffered a blunt chest trauma resulting in multiple intracardiac lesions: rupture of a tricuspid and an aortic valve leaflets, avulsion of a papillary muscle of the tricuspid valve, and rupture of the ventricular septum.
A 17-year-old Minorcan boy was celebrating a local festivity when he fell down and his chest was crushed by the hoof of a horse. He lost conciousness and was taken to a local hospital where he was discharged with the diagnosis of fracture of the sternum. Two days later, he had dizzy spells and vomiting, for which the family physician was consulted. He heard a heart murmur and the boy was flown to our hospital for further study and treatment. At admission, he was asymptomatic. A pansystolic murmur was heard at the left sternal border. Transesophageal echocardiography revealed tricuspid insufficiency and a left-to-right shunt between the right sinus of Valsalva and the right ventricle (Fig 1). Despite his lack of symptoms, it was decided that the cardiac lesions should be treated. He underwent surgery 1 month after the accident. A 6-mm tear was found in the anterior leaflet of the tricuspid valve, at the level of the insertion to the annulus. A papillary muscle of the posterior leaflet was avulsed. The right coronary cusp of the aortic valve presented a 4-mm tear. Under it, the membranous septum had ruptured, establishing a communication with the right ventricle (Fig 2). The anterior tricuspid leaflet was reinserted to the annulus and the torn papillary muscle was reimplanted to its base by means of a polytetrafluoroethilene suture. The tricuspid repair was completed with a Puig Massana ring (Shiley Inc, Irvine, CA). Due to the young age of the patient, it was decided to preserve the aortic valve. The tear was repaired with two 5-0 polypropilene sutures with Teflon (Impra Inc, subsidiary of L.R. Bard, Tempe, AZ) pledgets. The ventricular septal rent was also closed with a single U-stitch over pledgets. He made an uneventful recovery and was discharged. Two years later, he had several episodes of orthostatic hypotension and dyspnea. He was again referred to our hospital for evaluation. An echocardiogram showed moderate aortic insufficiency, but the left ventricular end-diastolic diameter had increased from 59 mm to 70 mm. He underwent reoperation. The repaired aortic leaflet had torn again. The valve was excised and replaced with a Monostrut prosthesis (Alliance Medical Technologies, Irvine, CA). The ascending aorta was enlarged with a Gore-Tex patch (W.L. Gore & Assoc, Flagstaff, AZ). His postoperative course was uneventful and he has been leading a normal life for the past 6 years, actively participating in the yearly horse-prancing festivities at his hometown.
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Fig 1. Preoperative transesophageal echocardiography. There is a tear in the right coronary cusp of the aortic valve (thick arrow) and rupture of the ventricular septum (thin arrow).
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Fig 2. Schematic representation of the intracardiac lesions. There was a tear in the anterior leaflet of the tricuspid valve with avulsion of the posterior papillary muscle. The arrow passes through a tear in the right aortic leaflet and a ruptured ventricular septum which created a left-to-right shunt.
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Comment
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Rupture of the tricuspid valve following closed chest tauma is due to acute compression of the heart between the sternum and the spine, resulting in an increased right heart pressure. The same mechanism can injure other cardiac structures such as the interventricular septum [1] or the aortic valve [2]. In our case, all three lesions concurred in the same patient. Tricuspid valve insufficiency can be due to a ruptured papillary muscle or to a tear in the leaflet. Both lesions accounted for the tricuspid insufficiency, while a ruptured right aortic cusp and the membranous part of the ventricular septum produced a left-to-right shunt. The mechanism of injury may account for the lesions in these three structures, which are in close vicinity, and for the lack of associated injuries to other organs, which commonly are associated with traumatic valve rupture [2, 3]. The boy sustained a sudden, severe hit by the hoof of a horse, which acted as a steam hammer on his chest. To better understand the injury, some comments on Balearic folklore are in order. In several towns of the island of Minorca, local festivities include several horsemen riding in the streets in front of a crowd. They make the horses walk on their hind legs, while the crowd tries to prevent the animal from regaining its four-legged status (Fig 3). (A local concoction made with gin, of which the islanders are very fond since the British domination in the 18th century, aids the crowd in such a foolish task). Our patient fell on his back and was hit on the chest by the horse as it was going down onto four legs. Other cases due to kicking by a horse or by a cow have been reported [2, 4], although the most common cause is motor vehicle accidents [2, 3].
Conservative repair of traumatic tricuspid rupture is the preferred treatment. In the largest series reported [2, 3], tricuspid valve replacement was the most common procedure performed, but valve repair has been performed with increasing frequency. We also elected conservative treatment of the aortic valve on the basis of the young age of the patient, but the repair failed and he had to be reoperated 2 years later. Long-term competence of a repaired aortic valve following trauma has been reported [5]. However, Okita and coworkers [6] recommend prosthetic replacement in patients older than 15 years of age, with aortic insufficiency associated with ventricular septal defect, due to the poor results of conservative treatment.
Timing of surgery is a debatable issue. Several reports indicate that it is not an emergency procedure, and surgeries up to 37 years following the accidents have been reported [2]. With the widespread use of echocardiography, these lesions will attain earlier recognition. Prompt surgical treatment should be undertaken once life-threatening injuries to other organs have resolved.
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Addendum
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After submission of the manuscript, a new case of tricuspid rupture due to a blow from a horse hoof on the chest wall has been reported [Bertrand S, et al. Tricuspid insufficiency after blunt chest trauma in a nine-year-old child. Eur J Cardiothorac Surg 1999;16:587–9]. Conservative repair of the valve was accomplished.
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Acknowledgments
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The authors are in debt to Pablo Umbert, MD, for the picture of the horse.
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References
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Schaffer R.B., Berdat P.A., Seiler C., Carrel T.P. Isolated fracture of the ventricular septum after blunt chest trauma. Ann Thorac Surg 1999;67:843-844.[Abstract/Free Full Text]
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Van Son J.A.M., Danielson G.K., Schaff H.V., Miller F.A. Traumatic tricuspid valve insufficiency. Experience in thirteen cases. J Thorac Cardiovasc Surg 1994;108:893-898.[Abstract/Free Full Text]
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Gayet C., Pierre B., Delahaye J.P., Champsaur G., Andre-Fouet X., Rueff P. Traumatic tricuspid insufficiency. An underdiagnosed disease. Chest 1987;92:429-432.[Abstract/Free Full Text]
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Sareli P., Goldman A.P., Pocock W.A., Colsen P., Casari A., Barlow J.B. Coronary artery-right ventricular fistula and organic tricuspid regurgitation due to blunt chest trauma. Am J Cardiol 1984;54:697-699.[Medline]
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Loop F.D., Hofmeir G., Groves L.K. Traumatic disruption of aortic valve. Cleve Clinic Q 1971;38:187-194.
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Okita Y., Miki S., Kushuhara K., et al. Long-term results of aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. J Thorac Cardiovasc Surg 1988;96:769-774.[Abstract]
Accepted for publication January 18, 2000.
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Abstract
Introduction
