Ann Thorac Surg 2003;76:923-925
© 2003 The Society of Thoracic Surgeons
Case report
Nonpenetrating right atrial and pericardial trauma
Antonino M. Grande, MDa*,
Mauro Rinaldi, MDa,
Stefano Pasquino, MDa,
Roberto Dore, MDb,
Mario Viganò, MDa
a Divisione di Cardiochirurgia, IRCCS Policlinico S. Matteo, Università degli Studi di Pavia, Pavia, Italy
b Istituto di Radiologia, IRCCS Policlinico S. Matteo, Università degli Studi di Pavia, Pavia, Italy
Accepted for publication January 26, 2003.
* Address reprint requests to Dr Grande, Divisione Cardiochirurgia, IRCCS Policlinico S. Matteo, P. le Golgi, 2, 27100 Pavia, Italy.
e-mail: amgrande{at}libero.it
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Abstract
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Nonpenetrating chest trauma can cause cardiac rupture. Ventricles are affected more frequently than atria. Survival is rare and depends upon prompt diagnosis and immediate surgical intervention. We report the case of a 42-year-old man involved in a car accident with consequent right atrial rupture and pericardial tearing.
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Introduction
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Nonpenetrating cardiac trauma is rare, often overlooked, and requires a great degree of speculation to obtain the right diagnosis. Cardiac contusions represent the most frequent type and usually have a benign clinical course. More severe forms of cardiac trauma are ventricular rupture—which occurs with the same incidence in the left or right ventricle—followed by right atrial rupture and left atrial injury [1]. We present a case of right atrial rupture and concomitant pericardial tear in a 42-year-old man who was involved in an automobile accident.
On July 15, 2000, the patient was admitted to the emergency room in a conscious state, hemodynamically stable, tachypneic, and with severe epistaxis. Roentgenograms showed a nasal fracture, a fracture of the upper third of the sternum, two left rib fractures, and a widened mediastinum. Electrocardiography showed sinus tachycardia. A computed tomography scan of the the patient’s chest showed anterior mediastinal hematoma and bleeding in the anterosuperior pericardial cavity (Fig 1).
Late sequential scans detected active bleeding in the anterosuperior pericardial portions that showed late contrast enhancement as do the great vessels (Fig 2).
This picture at first seemed to be consistent with an ascending aortic rupture. During the procedure the patient suffered sudden hypotension and loss of consciousness. He was immediately intubated and transferred to the operating room for an emergency operation.
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Fig 1. Computed tomography angiogram. (A) Right atrium appears in apparent normal shape during first phases of contrast enhancement. An anterior mediastinal hematoma (arrows) is near the atrium and a layer of fluid collection is in the mediastinal right pleura. (DA = descending aorta; la = left atrium; ra = right atrium.) (B) Mediastinal hematoma (arrows) and anterosuperior portions of the pericardium with bleeding. The shape of the ascending aorta and the superior vena cava is normal. (A = aorta; lpa = left pulmonary artery; lspv = left superior pulmonary vein; PT = pulmonary trunk; rpa = right pulmonary artery; svc = superior vena cava.)
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Fig 2. Late scan demonstrates active bleeding in the anterosuperior pericardial portions, which show late contrast enhancement as great vessels. No active bleeding is in the mediastinal hematoma (arrows) or in the right mediastinal pleural space. (A = aorta; DA = descending aorta; lpa = left pulmonary artery; PT = pulmonary trunk; ra = right atrium; rpa = right pulmonary artery.)
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The patient was immediately connected to extracorporeal circulation using femoral vessel bypass; the sternum was then opened through a midline incision. The pericardium was incised revealing a 0.5-cm laceration of the right atrium (Fig 3),
which was sutured with Prolene 4-0 sutures. The pericardium also had wide lateral tears facing the superior and inferior venae cavae (Fig 4).
Both pulmonary hila showed congestion and hemorragic infiltration. The postoperative course was uneventful, the patient achieved complete functional recovery, and 2 years later is in New York Heart Association class I.
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Fig 4. Operative finding: wide pericardial lacerations of the pericardium on its lateral aspect facing the superior and inferior venae cavae.
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Comment
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Myocardial contusion is the most frequent injury after blunt chest trauma. This condition is frequently not diagnosed but can be responsible for various cardiac arrhythmias. Ventricular thrombi are also associated with the regional wall motion abnormalities casued by myocardial contusion [2]. Septal [3] and free wall ruptures [4] are frequent: the left and right ventricles are involved with equal frequency, followed by the right atrium and the left atrium. Valve injuries after blunt trauma are rare [5]. In a recent review of the literature [4] it was reported that the main symptoms and signs in patients who had survived cardiac rupture were hypotension (100%), elevated central venous pressure (95%), tachycardia (89%), distended neck veins (80%), cyanosis of head, neck, arms, and upper chest (76%), unresponsiveness (74%), distant heart sounds (61%), associated chest injuries (60%), and increased heart shadow on chest x-ray films (59%). More than half of the patients in the reports included underwent pericardiocentesis, which can be therapeutic as well as diagnostic: drawing a small amount of blood can dramatically improve hemodynamics. In the case we describe here the concomitant pericardial tears caused an initial right hemothorax, preventing cardiac tamponade but causing hypovolemic hypotension.
The deceleration trauma was responsible for the laceration with a mechanism similar to thoracic aortic rupture: the main strain was at the level of the isthmus where the more mobile descending aorta is connected to the more fixed aortic arch. The venae cavae, the aorta, the pulmonary trunk, and the pulmonary arteries and veins firmly support the superior and posterior portion of the heart. During a deceleration trauma the anterior portion of the heart is therefore moved rapidly forward and this movement can cause a laceration. That explains why cardiac lacerations are found in the absence of sternal or costal fractures. Owing to the emergency situation we suspected an ascending aorta rupture; the right atrial laceration was only discovered at surgery.
We believe that all patients admitted to the emergency room who have sustained blunt chest trauma should undergo computed tomography scanning of the chest and echocardiography if the chest x-ray film shows an enlarged mediastinum, in order to diagnose a cardiac trauma immediately. In the case of deteriorating vital signs and uncontrollable hypotension, emergency median sternotomy should be performed to open the pericardium, relieve the tamponade, and try to control sources of bleeding that can be better identified through this approach.
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References
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- Parmley L.F., Manion W.C., Mattingly T.W. Nonpenetrating traumatic injury of the heart. Circulation 1953;18:371-396.
- Dumesnil J.G., Lentini S., Desanluier D. Vanishing posttraumatic left ventricular outflow tract thrombi. Ann Thorac Surg 1994;58:276.
- Aris A., Delgado L.J., Montiel J., Subirana M.T. Multiple intracardiac lesions after blunt chest trauma. Ann Thorac Surg 2000;70:1692-1694.[Abstract/Free Full Text]
- Leavitt B.J., Meyer J.A., Morton J.R., Clark D.E., Herbert W.E., Hiebert C.A. Survival following nonpenetrating traumatic rupture of cardiac chambers. Ann Thorac Surg 1987;44:532-535.[Abstract]
- Halstead J., Hosseinpour A.-R., Wells F.C. Conservative surgical treatment of valvular injury after blunt chest trauma. Ann Thorac Surg 2000;69:766-768.[Abstract/Free Full Text]
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Abstract
Introduction
