Ann Thorac Surg 2010;89:951-952. doi:10.1016/j.athoracsur.2009.07.082
© 2010 The Society of Thoracic Surgeons
Case Reports
Simultaneous Rupture of Bronchus and Aortic Valve From Blunt Trauma
Jennifer E. Samplesa,
Giorgio M. Aru, MDb,*,
Ervin Fox, MDc,
Walter H. Merrill, MDb
a Medical School, University of Mississippi, Jackson, Mississippi
b Division of Cardiothoracic Surgery, University of Mississippi, Jackson, Mississippi
c Division of Cardiology, University of Mississippi, Jackson, Mississippi
Accepted for publication July 23, 2009.
* Address correspondence to Dr Aru, Division of Cardiothoracic Surgery, University of Mississippi, 2500 N State St, Jackson, MS 39216 (Email: garu{at}surgery.umsmed.edu).
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Abstract
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We report the case of a 29-year-old woman with combined bronchial rupture and aortic valve tear after blunt chest trauma. She was successfully treated with primary repair of both lesions. The importance of chest computed tomography and transthoracic echocardiography in the diagnosis of these lesions is discussed.
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Introduction
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Nearly 30% of trauma patients have a cardiothoracic injury. A retrospective study of 1148 autopsies specifically reporting blunt trauma found a 2.8% incidence of tracheobronchial injury, with more than 80% of those patients dying in the field or shortly thereafter [1]. Traumatic aortic valve rupture is a rarity, accounting for only 0.73% of blunt force injuries found at autopsy in a sample of 546 patients [2]. We report a patient with blunt bronchial injury associated with aortic valve laceration that was treated with successful primary surgical repair.
A 29-year-old woman, who was a restrained back-seat passenger in a motor vehicle collision, presented with rib fractures, bilateral pneumothoraces, pulmonary contusions, and a mediastinal hematoma. Endotracheal and thoracostomy tubes were placed for respiratory distress and led to a small persistent air leak on the left side.
After consultation with our service 14 days later, the patient underwent chest computed tomography imaging and flexible fiberoptic bronchoscopy, which showed occlusion of the left mainstem bronchus 1 cm distal to the carina. During a right thoracotomy, intense scarring around the crushed left main stem bronchus was found and 1.0 cm of the bronchus was resected. A primary bronchial anastomosis with interrupted 4-0 Vicryl (Ethicon, Johnson & Johnson, Somerville, NJ) suture and right lung decortication were performed. Postoperative bronchoscopy demonstrated a widely patent bronchial anastomosis.
After extubation, the patient complained of orthopnea, dyspnea on exertion, and persistent hoarseness. A diastolic murmur was noted, and an echocardiogram revealed severe aortic regurgitation, severe tricuspid regurgitation, and a patent foramen ovale (PFO). During an urgent second operation, the right half of the left coronary cusp was found detached from the annulus at the commissure between the left and noncoronary cusps, leaving approximately a 1.0-mm rim of valve leaflet tissue attached to the annulus. A second smaller linear tear, parallel to the annulus, was found in the belly of the noncoronary cusp.
Because the aortic annulus was small and would have accepted only a 19-mm bileaflet valve, a primary repair of the left and noncoronary cusps was performed using 6-0 Prolene (Ethicon) in a double row: one horizontal mattress and one running stitch. The commissure was reattached. A No. 28 Cosgrove annuloplasty band (Edwards Lifesciences, Irvine, CA) was implanted in the dilated tricuspid annulus, and the PFO was closed primarily. A direct laryngoscopy also revealed a paralysis of the left vocal cord, possibly from blunt trauma to the intrathoracic left recurrent laryngeal nerve.
The patient was discharged on postoperative day 22 after the bronchial repair and postoperative day 6 after the aortic repair. An echocardiogram at 8 months demonstrated mild aortic regurgitation, mild tricuspid regurgitation, and good ventricular function (Fig 1). The result of chest roentgenogram was normal (Fig 2). Her hoarseness was also resolved.
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Comment
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Early diagnosis of tracheobronchial injury is critical because significant granulation tissue, stricture, and peribronchial scarring usually develop [3]. A persistent large air leak, with a pneumothorax poorly controlled by chest tube(s), is a typical but not constant presentation. A history of severe blunt trauma should raise a high index of suspicion and prompt a chest computed tomography evaluation, followed by bronchoscopy, if indicated. In our patient, the bronchial injury was not recognized until 14 days after hospitalization because the lung was expanded and the air leak was small.
The aortic tear in this patient was initially overlooked as well. The diagnosis of aortic valve injury after blunt trauma is delayed an average of 3 weeks (range, 4 hours to 4 years) [4]. This raises the question of performing a screening echocardiogram after any major chest trauma, an argument that is further strengthened when considering treatment for shock in these patients and making a distinction between hypovolemic shock, myocardial contusion, and any valvular lesion [5].
Although resection of the crushed bronchus and primary repair is a well established therapy, the treatment options for this patient's aortic valve included an aortic valve replacement with either a mechanical valve, a homograft, or a stentless valve, or an aortic valve repair. Owing to the patient's small aortic annulus, her plans for pregnancy, and the teratogenic potential of warfarin sodium, a mechanical valve would have been a less than an ideal replacement. A homograft valve could have been an acceptable but temporary replacement, with freedom from reoperation for structural deterioration at 15 years of 85% for the age bracket 21 to 40 years [6]. A stentless valve would have a similar durability, but reoperation is associated with an increased risk of death [7].
Some authors have discouraged surgical repair of the aortic valve owing to an 80% recurrence of incompetence [8]. However, we dispute their conclusions because the patients reviewed were from an earlier era when techniques and visual magnification were less than optimal. We also believe that, when feasible, a primary repair using a double row of monofilament—one horizontal mattress and one running stitch—is effective. In a horizontal mattress stitch, the tissue acts as a pledget in each needle passage, and the running stitch provides the seal.
On the basis of this case report and the results of 2 other patients with stab wounds to the right ventricular outflow tract and aortic valve, all of whom were successfully treated with primary repair and who achieved long term competency of the aortic valve, we believe that aortic valve repair is possible and is indicated in those simple lesions with linear tears that do not involve the entire cusp. Therefore, although replacement is the safest and most definitive treatment for complex valvular injuries, a repair should always be considered for simple lesions for which long-term valvular competency can be expected.
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References
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- Bertelsen S, Howitz P. Injuries of the trachea and bronchi Thorax 1972;27:188-194.[Abstract/Free Full Text]
- Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart Circulation 1958;18:371-396.[Abstract/Free Full Text]
- Patterson GA, Pearson FG, Cooper JD, et al. Pearson's thoracic and esophageal surgeryNew York: Churchhill Linvingstone; 2008. pp. 1755-1767.
- Pretre R, Faidutti B. Surgical management of aortic valve injury after nonpenetrating trauma Ann Thorac Surg 1993;56:1426-1431.[Medline]
- Fulda G, Brathwaite CEM, Rodriguez A, Turney SZ, Dunham CM, Cowley RA. Blunt traumatic rupture of the heart and pericardium: a ten year experience (1979–98) J Trauma 1991;31:167-173.[Medline]
- O'Brien MF, Harrocks S, Stafford EG, et al. The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements J Heart Valve Dis 2001;10:334-344.[Medline]
- Borger MA, Prasongsukarn K, Armstrong S, Feindel CM, David TE. Stentless aortic valve reoperations: a surgical challenge Ann Thorac Surg 2007;84:737-744.[Abstract/Free Full Text]
- German DS, Shapiro MJ, Willman VL. Acute aortic valvular incompetence following blunt thoracic deceleration injury: case report J Trauma 1990;30:1411-1412.[Medline]
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Abstract
Introduction
