Bettex, D.

Emmert, M.

Falk, V.

Hoerstrup, S.

Pretre, R.

Suendermann, S.

Weber, B.

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LETTER TO THE EDITORSSevere traumatic tricuspid insufficiency detected 10 yearsafter blunt chest traumaM. Y. Emmert • R. Pretre • S. Suendermann •B. Weber • D. A. Bettex • S. P. Hoerstrup •V. FalkReceived: 7 June 2010 / Accepted: 25 August 2010 / Published online: 15 September 2010 Springer-Verlag 2010Sirs:A 29 years old male patient was found to have a systolicmurmur on a routine medical examination. He was referredto a cardiologist for trans-thoracic echocardiography(TTE), which revealed a severe insufficiency of the tri-cuspid valve with a flail anterior leaflet due to completerupture of a papillary muscle (Carpentier’s Type II dys-function). The right ventricle was hypertrophic and dilatedwith a normal systolic function. There were no signs ofpulmonary hypertension and the left ventricular ejectionfraction was preserved (EF = 54%). The patient did nothave any cardiovascular history such as myocardialischemia, rheumatic fever or infective endocarditis. On theother hand, he mentioned to have had two severe caraccidents 11 and 10 years ago. In detail, he suffered fromtwo blunt, frontal chest traumas including multiple costalfractures and a clavicle fracture. Therefore, a traumaticinjury of the tricuspid valve was highly suspected. In thefurther history, the patient denied any cardiac symptomssuch as syncope, dyspnea, angina pectoris or palpitations,but reported occasional apical chest pains. The patient wasreferred to our tertiary center and was scheduled forsurgical repair of the tricuspid valve. An intraoperativetrans-esophageal echocardiography (TOE) confirmed thepreoperative findings (Fig. 1a, b). The operation was per-formed via classical sternotomy under cardiopulmonarybypass with bicaval cannulation. After opening the rightatrium, the rupture of the papillary muscle was confirmedand the anterior leaflet was massively extended. Theanterior leaflet was re-fixed using six Gore-Tex sutures asartificial chordae (69 Gore-Tex 6-0 sutures) and was sta-bilized with a rigid annuloplasty ring (Physio 34 mm,Edwards Lifesciences, Irvine, USA). The intraoperativeTOE revealed a successful repair of the valve withoutdetectable insufficiency (Fig. 2a, b). The rest of the pro-cedure was uneventful and the patient was referred to theICU. After 1 day in the ICU and 5 more days in the normalward, the patient was discharged and made a swift recov-ery. Three months after surgery, the patient was in goodcondition with no residual tricuspid regurgitation.We report a rare case of a severe tricuspid valveregurgitation following blunt chest trauma, which hasremained asymptomatic and undetected for over 10 years.Posttraumatic tricuspid valve insufficiency is a rareoccurrence, but due to its anterior location, it remains themost frequently reported valve injury following blunt chesttrauma [1]. Major mechanisms for traumatic tricuspidvalve injury include rupture of the papillary muscles,chordal disruption, free rupture of the valve leaflets orcomplete destruction of the valve [2].Although there have been many advances in echocar-diography, allowing a faster diagnosis and resulting in anearlier and more effective treatment, the diagnosis oftraumatic tricuspid valve insufficiency is often delayed oreven can be completely unrecognized,. Major reasons forthis problem are the general rarity, the absence or inho-mogeneity of symptoms and the presence of coexistinglife-threatening injuries such as hemato-pneumothorax,which have to be treated with priority, obscuring otherpathologies [3, 4]. For this reason, it is not exceptional forpatients to present years after the trauma [5]. In our patient,M. Y. Emmert (&)  R. Pretre  S. Suendermann  B. Weber S. P. Hoerstrup  V. FalkClinic for Cardiovascular Surgery, University Hospital Zurich,Raemi Street 100, 8091 Zurich, Switzerlande-mail: maximilian_emmert@web.deD. A. BettexInstitute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland123Clin Res Cardiol (2011) 100:177–179DOI 10.1007/s00392-010-0219-6the diagnosis was delayed for more than 10 years as thepatient was asymptomatic for the major part of the timeand reported to have only unspecific and irregular pain inthe apex area. In addition, the exact time of ruptureremained unclear, since he had two car accidents. Even ifhe had a follow-up echocardiography after the first acci-dent, it might be possible that he could have had an initialtrauma of the valve without rupture, but with elongation orinjury, and with the second trauma, or spontaneously, therupture could have occurred.The early symptoms usually reported are mainly fatigue,dyspnea on exertion and palpitations; sometimes, EKGsigns of incomplete or complete right bundle branch blockdue to a progressive dilatation of the tricuspid annulus maybe found. A progressive right heart dilatation, which mayend up with right heart failure, has been described [4].As seen in our case, patients can often tolerate acute rightheart volume overload and reach a compensated status,remaining asymptomatic for a long duration of time [4, 6].However, to prevent progressive right ventricular dys-function and preserve normal heart rhythm, early diagnosisand treatment are recommended and should be focusedwhenever possible [5].The surgical strategy should be adapted individually tothe patient’s specific pathology. Besides the general con-sensus to repair the valve whenever feasible [7], variousapproaches and techniques for effective surgical treatmenthave been described. The utilization of synthetic materialsto replace the ruptured chordae or papillary muscle hasbeen reported to be a promising strategy. In our case, weused Gore-Tex sutures to re-fix the anterior leaflet followedby the implantation of a rigid annuloplasty ring to reduceand stabilize the annular size, respecting Carpentier’sprinciples of valve repair.This report should alert all involved clinicians to con-sider traumatic tricuspid valve injury whenever a patientpresents with blunt chest trauma, even if they initiallyfocus on acute injuries. Furthermore, trans-thoracic orFig. 1 a,b Intraoperative trans-esophageal echocardiography (TOE)confirmed the preoperative findings and revealed a severe insuffi-ciency of the tricuspid valve with a flail anterior leaflet due to acomplete rupture of a papillary muscleFig. 2 a,b Intraoperative TOE displayed successful valve repairusing six artificial chordae and a stabilizing annuloplasty ring178 Clin Res Cardiol (2011) 100:177–179123trans-esophageal echocardiography is mandatory in thissetting and, even if it is not possible in the situation of anacute trauma, it should be routinely planned as a follow-upscreening.References1. Mattox KL, Feliciano DV, Burch J, Beall AC Jr, Jordan GL Jr,De Bakey ME (1989) Five thousand seven hundred sixtycardiovascular injuries in 4459 patients. Epidemiologic evolution1958 to 1987. Ann Surg 2096:698–705 discussion 706–72. Noera G, Sanguinetti M, Pensa P et al (1991) Tricuspid valveincompetence caused by nonpenetrating thoracic trauma. AnnThorac Surg 512:320–3223. Asbach S, Siegenthaler MP, Beyersdorf F, Bode C, Geibel A(2006) Aortic valve rupture after blunt chest trauma. Clin ResCardiol 9512:675–6794. Schuster I, Graf S, Klaar U, Seitelberger R, Mundigler G, Binder T(2008) Heterogeneity of traumatic injury of the tricuspid valve: areport of four cases. Wien Klin Wochenschr 12015(16):499–5035. van Son JA, Starr A (1995) Repair of traumatic tricuspid valveinsufficiency by trabecular muscle elevation. Ann Thorac Surg593:740–7426. Luo GH, Ma WG, Sun HS, Xu JP, Sun LZ, Hu SS (2005)Correction of traumatic tricuspid insufficiency using the doubleorifice technique. Asian Cardiovasc Thorac Ann 133:238–2407. Tang GH, David TE, Singh SK, Maganti MD, Armstrong S,Borger MA (2006) Tricuspid valve repair with an annuloplastyring results in improved long-term outcomes. Circulation1141(Suppl):I577–I581Clin Res Cardiol (2011) 100:177–179 179123

Severe traumatic tricuspid insufficiency detected 10years after blunt chest trauma

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Severe traumatic tricuspid insufficiency detected 10years after blunt chest trauma

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