Traumatic tricuspid insufficiency: a case report with a review of the literature

Traumatic tricuspid valve regurgitation: A two case series

Traumatic tricuspid valve injury is rare, accounting for 0.02% of traumatic injuries. The majority of cases result from blunt force trauma to the chest, however penetrating injuries have been documented in literature. Patients' can be in the full spectrum of disease, from asymptomatic to cardiogenic shock. Indications for surgery include right heart failure or evidence of right heart volume overload in the setting of significant tricuspid regurgitation. Early surgical repair is warranted to preserve right ventricular function. Surgery also needs to be planned in conjunction with the patients' other injuries. In some cases, it may be beneficial for surgery to be delayed whilst the patient is closely observed, in order for the patient to recover from concomitant injuries. We report two cases of tricuspid regurgitation in the context of blunt trauma, and our approach to the management of these patients.

A Case of Severe Tricuspid Regurgitation Related to Traumatic Papillary Muscle Rupture

A 25-year-old male presented after a motor vehicle accident with tricuspid valve (TV) regurgitation, due to a flail TV secondary to papillary muscle rupture. We highlight the importance of three-dimensional echocardiographic imaging of the tricuspid valve and its utility in aiding a successful surgical repair.

Traumatic severe tricuspid regurgitation diagnosis after the progression of right ventricle function deterioration

Traumatic tricuspid regurgitation is a rare complication of blunt cardiac injury and frequently misdiagnosed during the initial assessment. Unfortunately, it may be diagnosed after deterioration of right ventricle function, which may be fatal to the patient. Here, we report a case of a patient with blunt chest injury complicated by a diagnosis of traumatic severe tricuspid regurgitation after deterioration of the right ventricle function even after the patient was subjected to serum cardiac enzyme normalization. The patient was a driver and admitted to the hospital owing to multiple traumatic injuries. Echocardiography was performed suspicious of blunt cardiac injury, which revealed no abnormal findings. Initial cardiac enzyme levels were high, but after serial follow-up, the levels improved. However, on day 4 of hospitalization, hemodynamic deterioration occurred owing to severe tricuspid regurgitation and delayed right ventricle dysfunction. Immediate tricuspid valve replacement was performed, however, the patient had a pronged recovery period. We believe that it is important to take into account the nature of the accident and the presentation of clinical signs and symptoms and not be blinded by laboratory test results alone; it is also important to consider performing repeated serial echocardiographic examinations for blunt cardiac injury patients.

Non-functional tricuspid valve disease

Only 75% of severe tricuspid regurgitation is classified as functional, or related primarily to pulmonary hypertension, right ventricular dysfunction, or a combination of both. Non-functional tricuspid regurgitation occurs when there is damage to the tricuspid leaflets, chordae, papillary muscles, or annulus, independent of right ventricular dysfunction or pulmonary hypertension. The entities that cause non-functional tricuspid regurgitation include rheumatic and myxomatous disease, acquired and genetic connective tissue disorders, endocarditis, sarcoid, pacing, RV biopsy, blunt trauma, radiation, carcinoid, ergot alkaloids, dopamine agonists, fenfluramine, cardiac tumors, atrial fibrillation, and congenital malformations. Over time, severe tricuspid regurgitation that is initially non-functional, can blend into functional tricuspid regurgitation, related to progressive right ventricular dysfunction. Symptoms and signs, including a falling right ventricular ejection fraction, cardiac cirrhosis, ascites, esophageal varices, and anasarca, may occur insidiously and late, but are associated with substantial morbidity and mortality. Attempted valve repair or replacement at late stages carries a high mortality. Crucial to following patients with severe non-functional tricuspid regurgitation is attention to echo quantification of the tricuspid regurgitation and right ventricular function, patient symptoms, and the physical examination.

Correction of Traumatic Tricuspid Insufficiency Using the Double Orifice Technique

Traumatic tricuspid insufficiency is an uncommon clinical condition and surgical procedures vary. In this paper we report our experience in treating traumatic tricuspid insufficiency using the double orifice technique. From January 2000 to September 2003, 10 patients with traumatic tricuspid regurgitation were admitted to our hospital, 5 of whom were corrected using the double orifice technique. There were 4 males and 1 female with ages ranging from 31 to 52 years. Preoperative transthoracic echocardiography (TTE) detected severe tricuspid regurgitation in 4 patients and moderate tricuspid regurgitation in 1 patient. At surgery, tear of the tricuspid anterior papillary muscle was found in 2 cases and anterior chordal rupture in 3 cases. The valves were successfully repaired using the double orifice technique in combination with ring annuloplasty. There was no repeat operation, no operative complications or deaths. Before discharge, TTE detected normal tricuspid valve function in 2 cases and tiny regurgitation in 3 cases. After a follow up of 8 to 36 months, TTE demonstrated normal valve function in 1 patient and tiny regurgitation in 4 patients. The double orifice technique appears to be a simple but effective method of repairing traumatic tricuspid incompetence. Satisfactory clinical outcomes can be produced in carefully selected patients.

Surgical repair of tricuspid regurgitation due to annular detachment caused by chest trauma

Traumatic tricuspid valve regurgitation (TR) is a fairly rare complication of blunt chest trauma, and is usually caused by chordal and/or papillary muscle rupture. A 45-year-old woman, with a history of blunt chest trauma 16 years previously, was referred for surgery due to severe TR. During surgery, we found a large perforation on the right atrial wall located just anteriorly to the anterior leaflet, which was caused by annular detachment, in addition to anterior leaflet prolapse due to rupture of anterior chordae. The tricuspid valve was successfully repaired by direct closure of the perforation and chordal replacement with suture annuloplasty. Herein, we report a successful surgical repair of TR with annular detachment with right atrial dissection caused by blunt chest trauma. <Learning objective: Traumatic tricuspid valve regurgitation is rare, but one may encounter it from time to time. In this report, we describe the first case report of tricuspid annular detachment with fistula between the right atrium and the right ventricle caused by right atrial dissection, in which successful surgical repair was performed.>.

Traumatic rupture of the tricuspid valve and multi-modality imaging

INTRODUCTION

Motor vehicle accident (MVA) account for most cases of traumatic rupture of the tricuspid valve. Valve rupture during an MVA is generated by an abrupt deceleration coupled with an increase in right-side cardiac pressures (Valsalva maneuver and thorax compression).

CASE

A 39-year-old asymptomatic man was referred for an echocardiogram due to the presence of a systolic murmur. He had no prior significant medical history, except for a remote MVA 3 years ago. Real-time 3D echocardiography (RT3DE) showed a tear in the body of the anterior leaflet and not at the cord, as was suggested by two-dimensional transthoracic echocardiography (2D-TTE). Based on these findings, the mechanism was considered anterior leaflet rupture of the tricuspid valve, secondary to chest blunt trauma. The anterior leaflet was repaired using two polytetrafluoroethylene sutures, and tricuspid annuloplasty with an Edwards ring was performed.

CONCLUSIONS

Multimodality imaging helps to determine timing of surgery in asymptomatic traumatic tricuspid rupture. The combination of echocardiography and magnetic resonance imaging provide information of volumetric data and contractility of the right ventricle (RV) during follow-up. RT3DE gives information relevant to the morphological and functional characterization of the valve, allowing the planning of appropriate surgical procedure.

Traumatic tricuspid valve rupture presenting as third-degree atrioventricular block

BACKGROUND

Cardiac valve injury after blunt chest trauma is extremely rare, and the tricuspid valve is most commonly affected because of the anterior location of the right ventricle. Tricuspid valve insufficiency can range from a subclinical presentation to acute cardiac failure.

OBJECTIVE

Diagnosis is difficult in trauma patients because hypotension is usually attributed to hemorrhage and anatomical cardiac injuries might be overlooked.

CASE REPORT

This is a case of a 70-year-old patient with a history of rheumatic heart disease who suffered a complete rupture of her papillary muscles leading to tricuspid insufficiency after a motor vehicle collision. She presented with third-degree atrioventricular block.

CONCLUSIONS

Consideration of screening for anatomical heart injuries in blunt trauma patients with new onset dysrhythmias is recommended to explain hypotension not attributable to hemorrhage.

Role of imaging in penetrating and blunt traumatic injury to the heart

Cardiac injury due to blunt or penetrating chest trauma is common and is associated with significant morbidity and mortality. Understanding the mechanisms, types, and complications of cardiac injuries and the roles of various imaging modalities in characterizing them is important for appropriate diagnosis and treatment. These injuries have not been well documented at imaging, but there are now fast and accurate methods for evaluating the heart and associated mediastinal structures. The authors review the broad spectrum of injuries that can result from blunt or penetrating trauma to the chest, as well as the imaging modalities commonly used in the acute trauma setting for evaluation of the heart and mediastinal structures. A pictorial review of both common and, to date, rarely documented cardiac injuries imaged with a variety of modalities is also presented. While many imaging modalities are available, the authors demonstrate the value of multidetector computed tomography (CT) for the initial evaluation of patients with blunt or penetrating chest trauma. With the advent of multidetector CT, imaging of cardiac injury has increased and accurate identification of these rare but potentially lethal injuries has become paramount for improving survival. Selection of the most appropriate modality for evaluation and recognition of the imaging findings in cardiac injuries in the acute trauma setting is important to expedite treatment and improve survival.

Visualization of traumatic tricuspid insufficiency by three-dimensional echocardiography

A 19-year-old male was admitted to the emergency room of our hospital after a motor vehicle accident. During his first physical examination, a holosystolic murmur was heard at the fourth left parasternal border. Transthoracic echocardiography showed severe tricuspid insufficiency, but the cause of tricuspid insufficiency was unclear. Therefore, three-dimensional echocardiography was performed and demonstrated flail anterior, posterior and septal leaflets of the tricuspid valve. The diagnosis was tricuspid insufficiency due to papillary muscle rupture secondary to chest blunt trauma. Surgical repair of the tricuspid valve was performed in this patient. After surgery, the signs and symptoms of right ventricular heart failure were relieved. In this case, three-dimensional echocardiography was very useful for the evaluation of spatial destruction of the tricuspid valve and papillary muscle.

Traumatic tricuspid regurgitation following cardiac massage

We report a 66-yr-old male patient who developed tricuspid regurgitation secondary to internal cardiac massage. After uneventful off-pump coronary artery bypass surgery, the subject experienced cardiac arrest in the intensive care unit. External cardiac massage was initiated and internal cardiac massage was performed eventually. A transesophageal echocardiography revealed avulsion of the anterior papillary muscle and chordae to the anterior leaflet after successful cardiopulmonary resuscitation. Emergency repair of the papillary muscle was performed under cardiopulmonary bypass.

Mitral valve chordal rupture masquerades as endocarditis

Mitral valve chordal rupture is often associated with an inciting event. There are very few reported pediatric cases of spontaneous mitral valve chordal rupture. We describe a 9-year-old boy with a history of mitral valve prolapse who developed spontaneous mitral valve chordal rupture without evidence of endocarditis or trauma.

The Double Jeopardy of Blunt Chest Trauma: A Case Report and Review

Cardiac injury, specifically valvular rupture, must be considered after blunt chest trauma even in previously healthy patients. Isolated mitral regurgitation (MR) and tricuspid regurgitation (TR) due to blunt chest trauma are rare phenomena. More unique is simultaneous complete papillary muscle rupture of the mitral valve (MV) and tricuspid valve (TV) with only four patients being previously reported in the literature. This case describes a patient with complete transection of the posteromedial papillary muscle of the MV with severe MR and a concomitant flail TV with severe TR following a motor vehicular accident. The importance of transthoracic and transesophageal echocardiography in the early evaluation of patients following blunt chest trauma is also highlighted by this case.

Blunt cardiac injury associated with cardiac valve insufficiency: trauma links to chronic disease?

CONTEXT

Cardiac injury has been well recognised as a complication of blunt chest trauma. Its clinical spectrum ranges from blunt cardiac injury (BCI) to complete rupture of cardiac tissues, with cardiac valvular injury often being overlooked.

OBJECTIVE

To determine whether hospitalised BCI is associated with increased risk of cardiac valve insufficiency in a large multi-state hospitalised population.

METHODS

Cases with BCI and cardiac valve insufficiency were identified based on discharge diagnoses in 1997 statewide hospital discharge data from 19 states. Four valvular outcomes were studied: (1) mitral valve insufficiency, incompetence, regurgitation (MVIIR); (2) aortic valve insufficiency, incompetence, regurgitation, stenosis (AVIIRS); (3) tricuspid valve insufficiency, incompetence, regurgitation, stenosis (TVIIRS); and (4) pulmonary valve insufficiency, incompetence, regurgitation, stenosis (PVIIRS).

RESULTS

Among 1,051,081 injury discharges, 2709 (0.26%) people had BCI; 13,087 (1.25%) had MVIIR; 9811 (0.93%) had AVIIRS; 1338 (0.13%) had TVIIRS; 178 (0.02%) had PVIIRS. Independent of potential confounding factors, discharge for BCI was associated with a 12-fold increased risk for TVIIRS and a 3.4-fold increased risk for AVIIRS.

CONCLUSION

Cardiac valve insufficiency has been well recognised as an important risk factor for congestive heart failure. With the findings that BCI is associated with an increased risk of specific valvular disorders, it is possible that trauma may play an important and heretofore largely unrecognised role in a portion of the burden of cardiovascular morbidity and mortality.