Ann Thorac Surg 2009;88:983-985. doi:10.1016/j.athoracsur.2008.11.021
© 2009 The Society of Thoracic Surgeons
Case Reports
Acrocomia Aculeata as an Unreported Cause of Tricuspid Regurgitation
Ignacio Lugones, MDa,*,
Mariana López Daneri, MDb,
Willy M. Conejeros, MDa,
Maria Grippo, MDb,
Andres J. Schlichter, MDa
a Division of Cardiovascular Surgery, "Ricardo Gutiérrez" Children's Hospital, Buenos Aires, Argentina
b Division of Cardiology, "Ricardo Gutiérrez" Children's Hospital, Buenos Aires, Argentina
Accepted for publication November 10, 2008.
* Address correspondence to Dr Lugones, Calle 10 nro 857 Piso 13 B, La Plata, CP 1900, Argentina (Email: ignaciolugones{at}hotmail.com).
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Abstract
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Penetrating chest trauma can produce a wide range of lesions to cardiac structures. Some patients develop signs and symptoms of residual sequelae. We describe the case of an 11-year-old boy with severe tricuspid regurgitation caused by the thorn of a palm tree. A De Vega annuloplasty of the tricuspid valve and a bidirectional Glenn procedure were successfully performed 7 years after the episode. This case illustrates the importance of a thorough investigation of possible valvular heart disease in patients who suffered from chest trauma.
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Introduction
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Delayed sequelae after penetrating cardiac trauma are usual complications and most of them have to be operated on electively. We report a case of repair of tricuspid valve regurgitation 7 years after penetrating trauma caused by the thorn of a palm tree called Acrocomia aculeata.
An 11-year-old Paraguayan boy who had no history of known cardiac disease presented at our institution for evaluation of progressive dyspnea, asthenia, and palpitations. Physical examination revealed a heart rate of 150 beats per minute, irregular rhythm, positive jugular venous pulse, and hepathomegaly. On cardiac auscultation, a 4/6 holosystolic murmur was best heard at the right sternal border, fourth intercostal space. A chest roentgenogram revealed severe cardiomegaly. The electrocardiogram showed atrial flutter. Transthoracic echocardiography demonstrated severe tricuspid regurgitation and massive dilatation of the right atrium. The anterior leaflet of the tricuspid valve was severely damaged and was attached to the free wall of the right ventricle, downwardly displaced into the ventricular cavity away from the normally positioned annulus. The septal and posterior leaflets were normally implanted. The right ventricle was mildly reduced in size and showed severe dysfunction.
Surgery was undertaken for the repair of these lesions under cardiopulmonary bypass with moderate hypothermia. A median sternotomy was performed. Division of the pericardium revealed a single, thin localized adhesion of the pericardial sac to the anteroinferior right ventricular surface. The right atrium was dilated. As seen on echocardiography, the anterior leaflet of the tricuspid valve was severely damaged and the right ventricle showed importantly decreased contractility, so it was considered unsafe to rely solely on an annuloplasty of the tricuspid valve. Because of this, a bidirectional Glenn procedure was performed during cooling. Antegrade cold crystalloid cardioplegia was administered and the heart was arrested. The right atrium was opened and a part of its free wall was resected. In contrast with Ebstein's anomaly, both the posterior and septal leaflets of the tricuspid valve were normally implanted and presented normal morphology. Unexpectedly, at exploration of the anterior leaflet, a strange, black, and sharp object appeared. It was fixing the anterior leaflet in its opened position to the anterior ventricular wall (Fig 1). After being carefully removed, it was measured and turned out to be 2.5 inches long (Fig 2). Nobody in the operating room recognized the object. But at specific interrogation after surgery, the patient's mother said it was the thorn of a palm tree usually called "mbocayá" in rural areas of Paraguay, where they lived. This tree, whose scientific name is Acrocomia aculeata, is a large palm with a spiny trunk found in the open forests of South America. The mother said that 7 years prior the boy had stepped over the fallen trunk of a palm full of thorns and accidentally fell on it, resulting in multiple penetrating wounds. At that moment, he was assisted and many of them were removed from his body. Nobody realized that one still remained inside his thorax. As no specific symptomatology had developed and he had recovered fast and well, the mother forgot to mention the episode during the preoperative interrogation. Diminutive inespecific scars were present in the anterior chest and abdominal walls. Retrospective review of the preoperative echocardiogram with specific attention to the anterior leaflet of the tricupid valve revealed the little sharp tip of the thorn inmobilizing the leaflet and ending in the right fibrous trigone just beneath the atrioventricular node.
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Fig 1. Intraoperative view of the spine being removed from the anterior leaflet of the tricuspid valve. (AL = anterior leaflet of the tricuspid valve; Sp = spine.)
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After removing the thorn, a DeVega annuloplasty of the tricuspid valve was performed, narrowing the annulus over a 25-mm valve sizer. Two additional pledgeted sutures were placed in the anteroseptal comissure, closing this area in which the anterior leaflet was almost absent. The valve was tested and no regurgitation was observed.
The patient recovered uneventfully and was discharged 6 days later. Postoperative echocardiography demonstrated no residual tricuspid insufficiency.
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Comment
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Penetrating chest trauma can produce a wide variety of cardiac injuries. Commonly, multiple structures are injured, but the relative frecuency is related to its exposed area to the anterior chest wall [1].
Tricuspid regurgitation in this setting is uncommon. We believe that delayed repair of tricuspid regurgitation caused by the presence of a foreign body inside the heart has never been described before. There are some reasons for this. Penetrating cardiac injuries are usually lethal, and many patients die before receiving medical attention [2]. These wounds normally produce pericardial bleeding, which might cause cardiac tamponade and death. This bleeding leads to diffuse pericardial adhesions. Our patient presented only one small localized adhesion in the precise site of the injury, which makes us believe that no cardiac effusion developed after the accident.
Nowadays, gunshot and stab wounds are responsible for almost all these lesions. A chest roentgenogram is a useful method for detecting metallic objects, such as bullets. But other kind of foreign bodies, such as the thorn in this case, can go undetected because of its similar radiographic density to cardiac structures.
Traumatic intracardiac lesions, such as ventricular septal defects or mitral regurgitation, usually develop early symptomatology. But tricuspid regurgitation of acute development can be well tolerated, even for years [3]. Natural long-term evolution of cardiac lesions may produce different degrees of tissue healing, which can sometimes be beneficial. Ventricular septal defects, for example, can even close spontaneously. But valvular lesions usually worsen with time because leaflets become fibrotic and severely damaged [4].
Although in our patient, the exact cause of tricuspid regurgitation was not assessed until operation, transesophageal echocardiography continues to be the most reliable method for characterizing these injuries [5]. If they are not diagnosed at the initial time, delayed surgery should be planned according to the clinical status of the patient.
In conclusion, this unique case of penetrating heart trauma highlights the importance of thorough clinical and echocardiographic assessment of previously healthy patients presenting with cardiac disease and a history of chest trauma.
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References
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- Symbas PN, Harlaftis N, Waldo WJ. Penetrating cardiac wounds: a comparison of different therapeutic methods Ann Surg 1976;183:377-381.[Medline]
- Jenson B, Kessler RM, Follis F, Wernly JA. Repair of atrial septal defect due to penetrating trauma Tex Heart Inst J 1993;20:241-243.[Medline]
- Doty JR, Cameron DE, Elmaci T, Salomon NW. Penetrating trauma to the tricuspid valve and ventricular septum: delayed repair Ann Thorac Surg 1999;67:252-253.[Abstract/Free Full Text]
- Topaloglu S, Aras D, Cagli K, et al. Penetrating trauma to the mitral valve and ventricular septum Tex Heart Inst J 2006;33:392-395.[Medline]
- Salehian O, Teoh K, Mulji A. Ventricular septal defect secondary to penetrating trauma without pericardial effusion Can J Cardiol 2003;19:1437-1439.[Medline]
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Abstract
Introduction
