Ann Thorac Surg 2006;82:1093-1095
© 2006 The Society of Thoracic Surgeons
Case report
Delayed Traumatic Aortic Cusp Detachment Mimicking Aortic Dissection
Marco L.S. Matteucci, MD,
Giuseppe Rescigno, MD,
Gianluca Altamura, MD,
Marcello Manfrin, MD,
Alessandro D'Alfonso, MD,
Gianpiero Piccoli, MD,
Gianfranco Iacobone, MD*
AOUOORR Centro Cardiologico Lancisi, Ancona, Italy
Accepted for publication January 5, 2006.
* Address correspondence to Dr Matteucci, Cardiac Surgery, AOUOORR Centro Cardiologico Lancisi, Via Conca 71, 60020 Ancona, Italy (Email: sacha-m{at}libero.it).
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Abstract
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We report a case of delayed detachment of the right coronary cusp, occurring 12 days after a motorcycle crash. Echocardiographic findings mimicked a type I De Bakey aortic dissection. A brief discussion of cause, evolution, diagnosis, and treatment is included.
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Introduction
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Aortic regurgitation (AR) is a rare occurrence in patients surviving blunt chest trauma. The management of this complication is controversial with specific regard to the diagnostic tools and surgical timing.
A 33-year-old policeman was admitted to the emergency room of a local hospital after a motorcycle crash. Clinical evaluation revealed Glasgow Coma Scale 13 without hemodynamic impairment and severe multiple trauma to the head, thorax, and abdomen. A total body computed tomographic scan was performed, revealing absence of encephalic damage as well as thoracic and abdominal viscera involvement, and evidence of pelvis and left ischiopubis crus luxation with multiple face and right hand fractures.
After orthopedic correction of the hand fractures, while the patient was recovering in the intensive care unit, tachycardia developed and a murmur suggesting AR was first heard 10 days after admission. Patient was submitted to transthoracic echocardiogram with evidence of severe AR and type I De Bakey aortic dissection with an intimal tear in the right sinus of Valsalva.
The patient was transferred to our institution and a transesophageal echocardiogram revealed massive AR caused by complete detachment of the right coronary cusp everting into the aorta and mimicking an intimal tear in the ascending aorta (Fig 1), without any implication in the ascending aorta or the arch.
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Fig 1. Transesophageal echocardiography. (A, B) Right coronary cusp (RCC) detachment mimicking aortic dissection (arrows). (C) RCC flail (arrow). (D) Massive AR.
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Urgent aortic valve (AV) replacement by median sternotomy was performed. At cardiac arrest, after aortic cross-clamping, a transverse aortotomy was made. The aortic wall showed no abnormalities. At inspection of the native AV, the almost complete separation of the right coronary cusp from his attachment was found, the tear being about 15 mm in size (Fig 2). The annulus was intact, as was the left and noncoronary cusps. The AV was removed and replaced by a mechanical 23 bileaflet Sulzer Carbomedics (Austin, TX) prosthesis. The postoperative period was uneventful, and the patient was discharged 13 days postoperatively. The pathologic study showed that all three cusps were swollen without infiltration of inflammatory cells, although there was a laceration of the elastic fibre bundle of the right coronary cusp.
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Comment
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Cardiac injury is often overlooked in the initial assessment of a patient after trauma. With the advent of high speed travel, the incidence of traumatic rupture of the aorta has increased, reaching in some autopsy series one-fifth of deaths [1]. Williams and colleagues [2] reported that almost 60% of patients with aortic injury after thoracic trauma have an aortic transection, and that 65% of disruptions occur in the descending aorta close to the subclavian artery and only 14% in the ascending aorta.
Heart involvement, particularly right ventricle free wall rupture, is a rare occurrence and is more frequent in patients with penetrating trauma than with blunt chest trauma. Although AV is only rarely affected, it is the valve most frequently involved in blunt cardiac injury survivors [3]. Parmley and colleagues [4] found only one case of an isolated injury of the AV in 546 autopsies on patients dying as a result of blunt chest trauma. Posttraumatic AR is related either to valve lesion itself (ie, ruptured cusps) or to trauma of the ascending aorta (ie, subadventitial rupture with prolapse of the underlying AV cusp). Therefore, the most frequent valve lesion is the isolated injury of the noncoronary cusp (ie, a tear or an avulsion of the cusp itself or of a commissure) [3].
The mechanism of AV rupture has been experimentally demonstrated after blunt trauma to the sternum, particularly during early diastole, when significative pressure gradient can be generalized across a competent AV [3].
The clinical picture of posttraumatic AR is generally rapidly progressive, and the ineffectiveness of medical treatment has underlined the importance of early surgery. In the literature, a delay is frequent between trauma and the onset of AR symptoms. We might speculate that this delay may be caused by an initial small tear of the cusp at its attachment to the valve ring that progressively extends as a result of hemodynamic stress. As the valve cusp becomes separated from its annular attachment, AR progresses with a compensatory increase in the force of ejection and consequent increased hemodynamic stress to the valve cusp [3].
The diagnosis of posttraumatic AR is based on the history of blunt chest trauma and sudden onset of signs and symptoms of AR and transesophageal echo findings.
In the pre-echocardiograpic era, traumatic disruption of a previously normal valve, while suggested by history of chest trauma and clinical findings of AR, has been confirmed only at autopsy or operation. Transthoracic echocardiography is limited by poor resolution, especially in patients with rib fractures and those requiring chest drain tubes (ie, the group that may be at highest risk for traumatic cardiac involvement). Transesophageal echocardiography can overcome these limitations because it is inexpensive, rapid, and relatively safe, and because it has become the noninvasive technique of choice to diagnose and assess wall motion and valve function [5], allowing differential diagnosis between traumatic AR, acute bacterial endocarditis, and aortic dissection.
In our case, the history of chest trauma and absence of typical endocarditic findings helped us to preoperatively exclude acute bacterial endocarditis.
Only transesophageal echocardiography performed several days after the crash achieved the correct diagnosis, excluding the misleading picture of aortic dissection.
Despite the number of posttraumatic AR treated with conservative surgery, it is increasing in recent literature [6]. German and colleagues [7] reported a post-repair high recurrence rate [7]. We suggest that indications to valve replacement or repair depend on the extent of leaflet injury, and on the number of cusps or commissures involved. Despite that there was only one cusp involved in our case, we decided to replace the valve, because we were concerned by the chance that normal leaflets not involved in the laceration would be affected by posttraumatic tears visible only on microscopic examination, as reported by Egoh and colleagues [3], with a high risk of post repair AR.
The singularity of this case was based on the fact that (1) there was a delay between the trauma and the evidence of AR, and (2) there was a right coronary cusp detachment mimicking a transthoracic echocardiographic image of intimal tear on the ascending aorta, thus resulting in a misleading diagnosis of aortic dissection.
We conclude that in patients surviving blunt chest trauma, even when asymptomatic, a high index of suspicion is needed to avoid potentially lethal consequences and repeated physical examination aided by transesophageal echocardiography should be performed. Because traumatic perforation of the AV is often complicated with various abnormalities of the vessel, careful preoperative and intraoperative judgement are essential [3]. Furthermore, as long-term results of valve repair in posttraumatic AR are not yet available, we consider valve replacement the gold standard.
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References
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- Nzewi O, Slight RD, Zamvar V. Management of blunt thoracic injury Eur J Vasc Endovasc Surg 2006;31:18-27.[Medline]
- Williams JS, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicular trauma AnnThorac Surg 1994;57:726-730.[Abstract]
- Egoh Y, Okoshi T, Anbe J, Akasaka T. Surgical treatment of traumatic rupture of the normal aortic valve EurJCardiothoracSurg 1997;11(6):1180-1182.[Abstract]
- Parmley LF, Manion WC, Mattingly TW. Non penetrating traumatic injury of the heart Circulation 1958;18:371-396.[Medline]
- Weiss RL, Brier JA, O'Connor W, Ross S, Brathwaite CM. The usefulness of transesophageal echocardiography in diagnosing cardiac contusions Chest 1996;109:73-77.[Abstract/Free Full Text]
- Halstead J, Hosseinpour AR, Wells FC. Conservative surgical treatment of valvular injury after blunt chest trauma Ann Thorac Surg 2000;69:766-768.[Abstract/Free Full Text]
- German DS, Shapiro MJ, William VL. Acute aortic valvular incompetence following blunt thoracic deceleration injurycase report. J Trauma 1990;30:1411-1412.[Medline]
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Abstract
Introduction
