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Ann Thorac Surg 2007;83:289-291
© 2007 The Society of Thoracic Surgeons
Department of Surgery, Kurume University School of Medicine, Kurume, Japan
Accepted for publication June 1, 2006.
* Address correspondence to Dr Aoyagi, Department of Surgery (2), Kurume University School of Medicine, 67 Asahi-machi, Kurume 830–0011, Japan (Email: aoyagi{at}med.kurume-u.ac.jp).
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A 79-year-old man was admitted because of dyspnea on exertion. One month before admission, the patient had sustained left hemopneumothorax and fractures of the left clavicle and ribs as the result of a road traffic accident. The patient had been conservatively treated by chest tube drainage, but he had only a vague memory of medical examinations performed at the time. Three months before the traffic accident, the patient had received electrocardiographic and echocardiographic evaluations, and no cardiac abnormalities had been diagnosed.
On admission, auscultation of the chest revealed a to-and-fro murmur along the left sternal border. A chest roentgenogram showed mild cardiomegaly with pulmonary congestion and pleural effusion. An electrocardiogram revealed normal sinus rhythm and left ventricular hypertrophy with T wave inversion in leads V1-4. Echocardiography demonstrated marked left ventricular dilatation with moderate anteroseptal hypokinesis and prolapse of the noncoronary cusp with severe regurgitation. Moderate pericardial effusion was also detected.
Cardiac catheterization revealed moderate pulmonary hypertension and high left ventricular end-diastolic pressure. Aortography indicated severe aortic regurgitation but no intimal flap in the ascending aorta and no dilatation of the sinus of Valsalva was observed. Coronary arteriography showed dissection extending from the left main trunk to the proximal circumflex artery resulting in 50% stenosis of the left main trunk and significant stenosis (90%) of the posterolateral branch (Fig 1). Luminal irregularities were observed but no significant stenosis was found in the rest of the coronary arteries.
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A sudden increase in intrathoracic pressure leading to a concomitant increase in intraaortic pressure by a compressive or deceleration injury applied during early diastole is the main mechanism of aortic valve injuries such as tears of the cusps or avulsion of the commissures [1, 2]. The noncoronary cusp is most commonly involved because the runoff into the coronary arterial system protects the corresponding cusps by reducing the hydrostatic force against them [5].
Although some cases required immediate emergent operation, many previous studies [2, 6] have indicated patients who sustained traumatic aortic regurgitation had a variable asymptomatic period of weeks to years. A mechanism for delay between trauma and onset of symptoms has been speculated as an initially small tear of the cusp at its attachment to the valve ring progressively extends as the result of ordinary hemodynamic stresses. As the valve cusp becomes separated from its annular attachment, aortic regurgitation progresses with a compensatory increase in the force of ejection and consequent increased hemodynamic stress on the valve cusp. When aortic regurgitation becomes severe enough to cause pulmonary congestion, patients become symptomatic [6].
Valve replacement with a prosthetic valve has been the most common method to correct traumatic aortic regurgitation; however, successful valve repair was also reported [5]. In our patient, aortic valve replacement was performed because the avulsed commissure was too fibrous and stiffened to permit preservation of his native valve.
Coronary artery injury resulting from nonpenetrating chest trauma most often affects the left anterior descending artery [4]. The higher incidence of left anterior descending artery involvement may be due to its proximity to the chest wall. Compression of the anterior chest wall and the shear forces in the arterial wall generated by the sudden deceleration during impact are presumed to be the cause of the arterial injury [7].
Because electrocardiographic abnormalities or cardiac enzyme elevation may be the only indicators of myocardial and specific coronary artery injury, coronary arteriography should be urgently performed in patients with such abnormalities to limit the extent of infarction by catheter or surgical intervention.
Spontaneous healing of a coronary artery dissection has been reported in several cases [7]; however, surgical intervention, such as repair of dissection or coronary artery bypass grafting, is generally advocated [3, 8]. We performed coronary artery bypass grafting because it is a reliable and established procedure for securing coronary blood flow.
In conclusion, we describe the case of a patient who sustained nonpenetrating cardiac trauma that resulted in concomitant aortic valve rupture and dissection of the left main coronary artery. The patient was successfully managed with aortic valve replacement and coronary artery bypass grafting.
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This article has been cited by other articles:
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  S.-M. Park, D.-H. Kim, Y.-T. Kwak, and I.-S. Sohn Triple aortic root injury. Ann. Thorac. Surg., February 1, 2009; 87(2): 621 - 623. [Abstract] [Full Text] [PDF]
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