Subacute tricuspid regurgitation with severe hypoxemia complicating blunt chest trauma

Diagnostic Bedside Ultrasonography for Acute Respiratory Failure and Severe Hypoxemia in the Medical Intensive Care Unit: Basics and Comprehensive Approaches

Bedside goal-directed ultrasound is a powerful tool for rapid differential diagnosis and monitoring of cardiopulmonary disease in the critically ill patient population. The bedside intensivist is in a unique position to integrate ultrasound findings with the overall clinical situation. Medically critically ill patients who require urgent bedside diagnostic assessment fall into 2 categories: (1) acute respiratory failure and (2) hemodynamic derangements. The first portion of this review outlines the diagnostic role of bedside ultrasound in the medically critically ill patient population for the diagnosis and treatment of acute respiratory failure, acute respiratory distress, and severe hypoxemia. The second portion will focus on the diagnostic role of ultrasound for the evaluation and treatment of shock states, as well as describe protocolized approaches for evaluation of shock during cardiopulmonary resuscitation. Different respiratory system pathologies that result in acute respiratory failure (such as increased interstitial fluid, alveolar consolidation, pleural effusion) cause characteristic ultrasonographic findings; diaphragmatic assessment may also add information. Intracardiac shunting can cause severe hypoxemia. Protocolized approaches for the evaluation of patients with acute respiratory failure or distress are discussed.

Fossa ovalis tear causing right to left shunting in a Cavalier King Charles Spaniel

Left atrial tear is an infrequent sequela of severe mitral regurgitation due to myxomatous mitral valve degeneration. Interatrial septal tear due to mitral regurgitation causing a left-to-right shunt is uncommon. Right to left shunting secondary to acute interatrial septal tear is very rarely reported in the human literature, and has not been reported in the veterinary literature in a dog. This case describes the clinical, radiographic, echocardiographic, gross pathologic, and histopathologic features of a dog presented in acute respiratory distress secondary to acute onset right to left shunting through the interatrial septum. This was later documented to be due to a tear in the septum secondary to tricuspid regurgitation and pulmonary hypertension. The presence of an acquired right to left shunting atrial septal defect is of clinical and prognostic significance, and should be considered in cases of acute respiratory distress.

Atrial Septal Rupture, Flail Tricuspid Valve, and Complete Heart Block Due to Nonpenetrating Chest Trauma

This is a report of a patient with an atrial septal defect with right-to-left shunting, flail tricuspid valve, and complete heart block secondary to blunt chest trauma after a motor vehicle accident. The patient surgically repaired with pericardial recreation of atrial septum, bioprosthetic tricuspid valve replacement, and pacemaker insertion. The patient had minimal problems during the hospital course and subsequently made a full postsurgical recovery.

Delayed post-traumatic tamponade together with rupture of the tricuspid valve in a 15 year old boy

With the increase in the number of high speed motor vehicle accidents, blunt, non-penetrating trauma to the heart has become an important health problem. An unusual case is reported of a 15 year old boy urgently referred with cardiac tamponade and a new systolic murmur four months after a car accident. The problems of the diagnosis and possible causes of late cardiac tamponade and tricuspid regurgitation following this type of accident are discussed.

Ruptured chordae tendineae of the posterior leaflet of the tricuspid valve as a cause of tricuspid regurgitation following blunt chest trauma

A 12-year-old boy suffered a blunt chest trauma. Some hours later, a pulsatile bilateral jugular venous distension, a holosystolic murmur heard at the low parasternal border and hepatomegaly were observed. On echocardiography, ruptured chordae tendineae of the posterior leaflet of the tricuspid valve, as well as tricuspid regurgitation were detected. He remained asymptomatic during hospital stay and was discharged home in good condition. Thus, isolated ruptured chordae tendineae of the posterior leaflet of the tricuspid valve is another cause of tricuspid regurgitation following blunt chest trauma.

Acute right-to-left inter-atrial shunt; an important cause of profound hypoxia

Three patients presented to our intensive care unit over a 3-yr period with profound hypoxia resulting from acute right-to-left inter-atrial shunt (RLIAS). Patient 1 was a 67-yr-old male with an atrial septal defect who became hypoxic and developed the rare sign of platypnoea following elective repair of an abdominal aortic aneurysm (breathlessness made worse when upright and relieved by lying flat). Patient 2 was a 38-yr-old female who developed platypnoea and hypoxia secondary to a patent foramen ovale (PFO) and pericardial effusion. Patient 3 was a 46-yr-old male with a PFO who developed hypoxia without platypnoea because of multiple pulmonary emboli following right hemicolectomy. These case reports illustrate the need to consider RLIAS as a cause of hypoxia of sudden onset. Early use of bubble contrast echocardiography is indicated.

Rupture of the atrial septum and tricuspid valve after blunt chest trauma

A previously fit 19-year-old male driver was involved in an unrestrained, head-on collision. Transesophageal echocardiography revealed rupture of the chordae subtending both leaflets of the tricuspid valve with severe tricuspid regurgitation and disruption of the interatrial septum. When cardiac injury is suspected after blunt chest trauma, transesophageal echocardiography facilitates appropriate management as it provides safe, rapid, and accurate diagnostic images.