Traumatic rupture of the tricuspid valve

Traumatic rupture of the tricuspid valve is a rare and difficult entity to diagnose as it usually courses asymptomatic; therefore, clinical suspicion is key to identify it. We report the case of a 48-year-old male patient who was admitted due to closed thoracic trauma after falling from 4 meters high. The echocardioscopy performed in the Emergency Room was normal. The patient was transferred to the Intensive Care Unit due to pulmonary contusion and multiple rib fractures. Lab tests revealed elevation of myocardial necrosis markers, and ECG showed RBBB. A new echocardiography, performed 48 hours later to rule out complications secondary to myocardial contusion, targeted the tricuspid valve with papillary muscle rupture and eversion of the anterior leaflet causing massive tricuspid regurgitation (TR) (opacifying the right atrium; Doppler triangular flow did not allow pulmonary pressure measurement; there was systolic inversion in suprahepatic vein flow, paradoxical septal motion associated with volume overload), slightly enlarged right chambers with preserved right ventricular systolic function, and mild pericardial effusion. ... La rotura traumática de la válvula tricúspide es una entidad infrecuente y difícil de diagnosticar, ya que habitualmente cursa de forma asintomática, lo que hace fundamental la sospecha clínica para poder identificarla. Presentamos el caso de un varón de 48 años que ingresa por traumatismo torácico cerrado tras precipitarse desde 4 metros de altura. Se realizó ecocardioscopia en urgencias que fue normal. El paciente ingresó en la unidad de cuidados intensivos por contusión pulmonar y múltiples fracturas costales. En la analítica presentó elevación de marcadores de necrosis miocárdica y en ECG BRDHH, por lo que a las 48 h se realizó un nuevo ecocardiograma para descartar complicaciones secundarias a la contusión miocárdica; en este se observó la válvula tricúspide con rotura del músculo papilar y eversión del velo anterior, lo que produce insuficiencia tricuspídea (IT) masiva (opacifica toda la aurícula derecha; el flujo Doppler triangular no permite estimar la presión pulmonar; inversión sistólica del flujo en las venas suprahepáticas, movimiento paradójico del septo en relación con sobrecarga de volumen), cavidades derechas ligeramente dilatadas con función sistólica VD conservada y derrame pericárdico ligero. El paciente presentó una evolución tórpida con volet costal complicado con fracaso multiorgánico, por lo que, dada la ausencia de signos de insuficiencia cardíaca derecha, se decidió demorar la cirugía cardíaca. A los 6 meses, se realizó la reparación de la válvula tricúspide mediante anuloplastia, neocuerda a velo anterior y plicatura al nivel de la comisura entre el velo septal y el anterior. Posteriormente, el paciente presentó buena evolución clínica y ecocardiográfica con IT grado II/IV y normalización de la dilatación de cavidades derechas

Key Factors Associated With Pulmonary Sequelae in the Follow-Up of Critically Ill COVID-19 Patients

Introduction: Critical COVID-19 survivors have a high risk of respiratory sequelae. Therefore, we aimed to identify key factors associated with altered lung function and CT scan abnormalities at a follow-up visit in a cohort of critical COVID-19 survivors. Methods: Multicenter ambispective observational study in 52 Spanish intensive care units. Up to 1327 PCR-confirmed critical COVID-19 patients had sociodemographic, anthropometric, comorbidity and lifestyle characteristics collected at hospital admission; clinical and biological parameters throughout hospital stay; and, lung function and CT scan at a follow-up visit. Results: The median [p25–p75] time from discharge to follow-up was 3.57 [2.77–4.92] months. Median age was 60 [53–67] years, 27.8% women. The mean (SD) percentage of predicted diffusing lung capacity for carbon monoxide (DLCO) at follow-up was 72.02 (18.33)% predicted, with 66% of patients having DLCO < 80% and 24% having DLCO < 60%. CT scan showed persistent pulmonary infiltrates, fibrotic lesions, and emphysema in 33%, 25% and 6% of patients, respectively. Key variables associated with DLCO < 60% were chronic lung disease (CLD) (OR: 1.86 (1.18–2.92)), duration of invasive mechanical ventilation (IMV) (OR: 1.56 (1.37–1.77)), age (OR [per-1-SD] (95%CI): 1.39 (1.18–1.63)), urea (OR: 1.16 (0.97–1.39)) and estimated glomerular filtration rate at ICU admission (OR: 0.88 (0.73–1.06)). Bacterial pneumonia (1.62 (1.11–2.35)) and duration of ventilation (NIMV (1.23 (1.06–1.42), IMV (1.21 (1.01–1.45)) and prone positioning (1.17 (0.98–1.39)) were associated with fibrotic lesions. Conclusion: Age and CLD, reflecting patients’ baseline vulnerability, and markers of COVID-19 severity, such as duration of IMV and renal failure, were key factors associated with impaired DLCO and CT abnormalities