Ann Thorac Surg 2009;87:621-623. doi:10.1016/j.athoracsur.2008.07.035
© 2009 The Society of Thoracic Surgeons
Case Reports
Triple Aortic Root Injury
Sung-Min Park, MDa,*,
Dae-Hyun Kim, MDa,
Young-Tae Kwak, MDa,
Il-Suk Sohn, MDb
a Department of Thoracic and Cardiovascular Surgery, Kyung Hee University East-West Neo Medical Center, Seoul, Korea
b Department of Cardiology, Kyung Hee University East-West Neo Medical Center, Seoul, Korea
Accepted for publication July 9, 2008.
* Address correspondence to Dr Park, Kyung Hee University East-West Neo Medical Center, 149 Sangil-Dong Gandong-Gu, Seoul, 134-890, Korea (Email: heartlung{at}gmail.com).
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Abstract
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Nonpenetrating aortic root injuries, including aortic transection, coronary artery dissection, and aortic valve disruption, are very rarely seen and difficult to diagnose. This case was determined to be a combination of all three of these injuries. The management of this patient's injuries was also a challenge because of a history from previous drug-eluting stent implantation.
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Introduction
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Ascending aortic transection, aortic valve rupture, and coronary dissection in blunt trauma is very rare; we believe there has been no prior report on these three injuries shown together to date [1, 2]. Aside from the exceedingly low incidence associated with this condition, we report this case with all three of these injuries, which was further complicated by a previous drug-eluting stent implantation in the left anterior descending coronary artery (LAD).
A 46-year-old man was admitted to the emergency department after a car accident complaining of chest pain. One month before the accident he had undergone percutaneous coronary intervention with drug-eluting stent implanted in the LAD and was receiving antiplatelet medication including clopidogrel. The initial blood pressure was 120/80 mm Hg. The bedside electrocardiogram demonstrated sinus tachycardia and right bundle branch block. The initial laboratory examination showed a hemoglobin level of 14.2 g/dL and a troponin I level of 3.74 ng/mL. Radiologic findings revealed a sternum fracture and right second and third rib fractures. On the chest computed tomography, a focal dissection of ascending aorta was noticed (Fig 1A). Because of the past history of percutaneous coronary intervention, coronary angiography was performed; the LAD was intact, but a small filling defect was found on the proximal right coronary artery (RCA; Fig 1B). Preoperative transesophageal echocardiogram showed an eccentric regurgitation of the aortic valve in the noncoronary cusp (Fig 1C).
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Fig 1. (A) A pseudoaneurysm of the ascending aorta (white arrow) shown on chest computed tomographic scan. (B) The coronary artery bypass graft shows a small contrast media filling defect (black arrow) in the proximal right coronary artery. (C) Preoperative transesophageal echocardiography demonstrates aortic regurgitation through the noncoronary cusp.
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The operation was conducted through a median sternotomy. A pericardial tear near the right superior pulmonary vein and a hemorrhagic change along the epicardial surface of the RCA was noticed (Fig 2A). Opening the ascending aorta revealed the transverse tearing of the aortic wall just above the aortic valve, and a perforation in the middle of the noncoronary cusp (Figs 2B and C). The intimal dissection of the RCA ostium was also detected. The noncoronary cusp was repaired with 6-0 Prolene (Ethicon, Somerville, NJ),and the dissection of the RCA ostium was sutured with 5-0 Prolene (Ethicon). The ascending aorta was replaced with a 28-mm Dacron graft (Gelseal, Vascutek Ltd, Inchinnan, UK), and the RCA was bypassed with a saphenous vein graft. After the repair, the transesophageal echocardiogram showed no aortic regurgitation.
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Fig 2. (A) Hemorrhagic discoloration of the epicardium (black arrow) along the right coronary artery. (B) Ascending aortic tear (white arrow) located just above the aortic valve. (C) Perforation of the noncoronary cusp (small arrow). (Ao = ascending aorta.)
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There was extensive perioperative blood loss, requiring a large volume of blood transfusions. Estimated blood loss during the surgery was about 3,000 mL. During the surgery, 8 units of packed red blood cells (1 unit = 250 mL), 5 units of fresh frozen plasma (1 unit = 190 mL), and 8 units of platelet concentrates (1 unit = 35 mL) were transfused. The postoperative chest drain was more than 1,000 mL per day during the first 3 postoperative days. During this period, 9 units of packed red blood cells, 10 units of fresh frozen plasma, and 18 units of platelet concentrates were transfused to maintain the hematocrit level above 26% and to correct the prolonged bleeding time (>5 min).
On postoperative day 6, atrial fibrillation developed, and a loculated intrapericardial fluid collection was noticed on the echocardiographic scan; this was managed conservatively with the administration of Cordarone (amiodarone; Sanofi-Aventis, Paris, France) and cardioversion. After 15 days in the intensive care unit, the patient was moved to the general ward; then 38 days after the operation he was discharged. Three months after the surgery, chest computed tomography was performed, which showing resolved pericardial fluid and no pseudoaneurysm or dissection of the aorta. A recent echocardiography, 7 months after the operation, showed minimal aortic regurgitation. Otherwise, the cardiac function was normal. Currently, 8 months after the operation, the patient does not have any cardiovascular symptoms.
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Comment
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In blunt trauma, the most commonly injured site of the ascending aortic transection is just above the aortic valve, and aortic valve disruption usually involves the noncoronary cusp [1, 3]. The presented case is typical of these two injuries. Together with the RCA dissection, these injuries originate from the aortic root. The simultaneous presentation of these three injuries around the aortic root suggests that they might share the same injury mechanism. One of the mechanisms of the injury is external compression during the early diastole when the ascending aorta is fully dilated and the aortic valve is closed. The sinuses of Valsalva are full of blood volume and the external compression increases the wall tension, resulting in the rupture of the structures where stress is the highest, usually at the noncoronary leaflet [3, 4]. Another mechanism is the shear stress caused by deceleration force [5]. The expanded blood volume most likely increased the momentum of the ascending aorta, lending itself more prone to rupture.
Although there is no clinical data about the incidence of coronary artery injury after blunt trauma in patients with coronary stents, we decided to have a coronary angiography before the operation because the patient had a coronary stent implanted in the LAD, which is the most frequently injured coronary artery in nonpenetrating chest trauma [3].
Patients with ascending aortic transection should be operated on as soon as possible if there are no other organ injuries that add unacceptable risk to the surgical treatment [1]. The recent reports suggest that the surgery for aortic isthmus injury can be delayed safely, but the data for ascending aortic transection is limited [1, 6].
In the presented case, the patient had been receiving triple antiplatelet therapy including clopidogrel. Clopidogrel, is known to increase the risk of perioperative bleeding. On the other hand, withdrawing this agent increases the incidence of acute myocardial infarction [7]. Concerning the risks of aortic rupture, we decided to perform an early operation on the patient. Because of the drug-eluting stent in LAD, early postoperative antiplatelet therapy was required. However, prolonged mediastinal bleeding made it difficult to decide the timing of postoperative clopidogrel administration.
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References
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- Symbas PJ, Horsley WS, Symbas PN. Rupture of the ascending aorta caused by blunt trauma Ann Thorac Surg 1998;66:113-117.[Abstract/Free Full Text]
- Silva R, Prieto D, Antunes P, Antunes MJ. Repair in traumatic ascending aortic rupture and valve insufficiency Interact Cardiovasc Thorac Surg 2004;3:398-400.[Abstract/Free Full Text]
- Aoyagi S, Okazaki T, Fukunaga S, Ueda T. Concomitant traumatic aortic valve and coronary artery injury Ann Thorac Surg 2007;83:289-291.[Abstract/Free Full Text]
- Grande KJ, Cochran RP, Reinhall PG, Kunzelman KS. Stress variations in the human aortic root and valve: the role of anatomic asymmetry Ann Biomed Eng 1998;26:534-545.[Medline]
- Cheng I, McLellan BA, Joyner C, Christakis G. Aortic root trauma: serious injuries requiring early recognition and management J Trauma 2000;48:525-529.[Medline]
- Galli R, Pacini D, Di Bartolomeo R, Fattori R, Turinetto B, Grillone G, Pierangeli A. Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta Ann Thorac Surg 1998;65:461-464.[Abstract/Free Full Text]
- Brilakis ES, Banerjee S, Berger PB. Perioperative management of patients with coronary stents J Am Coll Cardiol 2007;49:2145-2150.[Abstract/Free Full Text]
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Abstract
Introduction
