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A Rupture of Both Atrioventricular Valves After Blunt Chest Trauma: The Usefulness of Transesophageal Echocardiography for a Life-Saving Diagnosis

Petkov, Milen P. MD*; Napolitano, Charles A. MD, PhD*; Tobler, H Gareth MD; Ferrer, Thomas J. MD; Palacios, J Mauricio MD*; Wangler, Michael D. MD*

doi: 10.1213/01.ANE.0000149543.15866.80
Cardiovascular Anesthesia: Case Report

Survival after the rupture of the both mitral and tricuspid valves in blunt thoracic trauma is uncommon and requires prompt diagnosis and treatment. We present a case in which transesophageal echocardiography performed in the operating room by the anesthesiologist identified the etiology of hemodynamic instability and facilitated successful emergency replacement of both valves.

IMPLICATIONS: Traumatic rupture of both atrioventricular valves was revealed by transesophageal echocardiography in the operating room. Prompt diagnosis and timely surgery were critical for the favorable outcome in this patient.

From the Departments of *Anesthesiology and ‡Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Accepted on publication October 19, 2004.

Address correspondence and reprint requests to Michael D. Wangler, MD, Associate Professor, Department of Anesthesiology, Slot #515, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR 72205. Address e-mail to mwangler@uams.edu.

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Case Report

A 35-yr-old, 1.7 m, weighting 75 kg, unrestrained male driver was involved in a head-on collision. There were fatalities in both vehicles and extensive damage to the patient’s vehicle including a broken steering wheel. After a prolonged extrication at the scene the patient was transported to our hospital on a backboard, with cervical collar and 16-gauge peripheral IV catheter. On arrival the patient was awake and responsive but disoriented with heart rate 150 bpm. The trauma team was unable to detect any murmurs. His arterial blood pressure (BP) was 84/42 mm Hg. A tension pneumothorax was clinically diagnosed and a right chest tube was placed. Despite the chest tube and what was believed to be adequate fluid resuscitation, inadequate perfusion persisted, as the BP continued to decrease to less than 80 mm Hg systolic. Other findings included a left hip dislocation/acetabular fracture with ischemic leg, a left proximal humerus fracture, and chest and head contusions and lacerations. Arterial blood analysis on arrival showed pH 7.04, Pco2 61.7 mm Hg, Po2 107 mm Hg, HCO3 16.5 meQ/L, base excess −14, and hematocrit of 31%.

Chest radiograph revealed increased density in the right upper lung consistent with contusion/hemorrhage, indistinct margins of the aorta, and prominence of the superior mediastinum. An abdominal ultrasound examination performed in the emergency room revealed no bleeding. The electrocardiogram was grossly abnormal, showing sinus tachycardia with first-degree atrioventricular (AV) block, biatrial enlargement, right bundle branch block and left anterior fascicular block. Left ventricular hypertrophy with QRS widening and repolarization abnormality were also apparent. All these were consistent with the diagnosis of cardiac contusion that was later confirmed by a Troponin I concentration of 115.2 μg/L.

Given the patient’s unstable hemodynamic condition the decision was made to proceed directly to the operating room (OR) to secure an airway and reduce his hip dislocation and perform a diagnostic peritoneal lavage with the possibility of an exploratory laparotomy. Right subclavian central venous catheter (9F Cordis) revealed a central venous pressure of 11 mmHg and the waveform revealed large V-waves.

In the OR a rapid anesthetic sequence induction with inline stabilization during tracheal intubation was performed without difficulty. This was facilitated by fentanyl 50 μg, etomidate 14 mg, and succinylcholine 120 mg without significant hemodynamic changes.

In view of the patient’s clinical presentation and the nature of his trauma, transesophageal echocardiography (TEE) was performed by the anesthesiology team to exclude aortic injury, pericardial tamponade, or myocardial contusion. This was done concurrently with the hip reduction and the diagnostic peritoneal lavage. A Vivid 3 - Cardiovascular Ultrasound System with T6 multiplane transesophageal probe was used. The TEE revealed no pericardial effusion and good left ventricular contractility. Examination of the mitral valve (MV) revealed rupture of the anterolateral papillary muscle (Figure 1, left) with severe mitral regurgitation (Figure 1, right) and systolic reversal of the pulmonary vein flow. Examination of the tricuspid valve (TV) similarly revealed a flail valve with severe regurgitation (Fig. 2). The aorta was intact.

Figure 1

Figure 1

Figure 2

Figure 2

Cardiothoracic surgery was consulted immediately and cardiology was consulted to confirm the findings. Meanwhile, the diagnostic peritoneal lavage was clinically con-sidered to be borderline positive for blood, and subsequent laboratory analysis demonstrated 450,000 erythrocytes/mL (positive is considered above 100,000). After discussion between the cardiothoracic and general surgical teams, it was determined that the injuries of highest priority were the flail AV valves. Thus, with the general surgical team on standby, in case of significant intraabdominal bleeding, the patient underwent full cardiopulmonary bypass (CPB) for replacement of the MV and TV. To this moment the patient was resuscitated with 5.5 L crystalloid solution and 4 U packed red blood cells (PRBC). An arterial catheter and a second 16-gauge peripheral IV catheter were inserted. Anesthesia was maintained with 0.5%–0.7% isoflurane in addition to fentanyl and versed boluses. The circuit used for the CPB was a Medtronic custom perfusion pack: closed, heparin coated with leukocyte depleting filter. Heparin 16,000 U was given to keep the activated clotting time more than 400 seconds. Myocardial protection was assured with cold cardioplegia to keep the heart temperature <15°C. The duration of the aortic cross-clamp was 143 and CPB time was 217 min. One L crystalloid solution, 4 U fresh-frozen plasma, 2 U of platelets, and 1 U of PRBC were administered in addition to the retransfusion from the cell saver. Intraoperative findings confirmed the TEE diagnosis: the anterolateral papillary muscle was found to be avulsed from the myocardium with a flail mitral anterior leaflet. There was bruising of the right ventricle and the septal papillary muscle was completely avulsed from the right ventricular septum with a flail TV. There was also a significant laceration of the posterior pericardium extending from the apex of the pericardium posteriorly on the left side to above the left superior pulmonary vein. The nature of the injuries and the extent of the bruising precluded primary repair as an option. The MV was replaced with a 31 mm St. Jude extended cuff prosthesis and the TV was replaced with a 33 mm regular Master Series extended cuff prosthesis. Although there was good contractile function of the left ventricle, poor right ventricular function required inotropic support with milrinone and epinephrine to wean the patient from CPB. TEE on postoperative day (POD) 1 demonstrated a severely hypokinetic right ventricle that showed improvement on the follow-up echocardiograms at POD 7, POD 9, and POD 19. Because of the inability to navigate a pulmonary artery catheter through the prosthetic TV, cardiac outputs were determined by a noninvasive cardiac output monitor (Novametrix NICO®, Respironics Inc., Wallingford, CT) during the early postoperative course. A postoperative brain/face computed tomography (CT) scan revealed a hemorrhagic contusion in the left inferior frontal lobe measuring 1.9 × 1 cm and minimally displaced nasal bone fractures. The brain lesion appeared stable with some surrounding edema but no significant mass effect and was followed to resolution by POD 14. Abdominal CT showed a hemoperitoneum, which was later identified as originating from a small contained splenic laceration that did not require surgical intervention. The patient was tracheally extubated on POD 5 and returned to the OR POD 9 for repair of his left acetabular fracture. Anticoagulation was withheld until the resolution of the hemorrhagic brain contusion. Before discharge Coumadin therapy was started. On POD 23 the patient was discharged. On discharge the patient did not have any motor or sensory deficits. There was some antegrade amnesia for the first days after the accident as well as mild impairment in short-term memory and concentration. Pathologic diagnosis of the intraoperative specimen was valves with focal myxoid degeneration and papillary muscles with focal fibrosis.

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Discussion

The decision for early heart surgery in the trauma patient is difficult (1) because of the increased risk of bleeding during heparinization. Timely diagnosis and prompt cardiac repair were crucial for this patient’s survival. As a rule, early surgery is indicated in patients with MV rupture presenting with hemodynamic instability and dangerous hypoxemia refractory to conservative treatment (2,3). Isolated TV damage is associated with less prominent hemodynamic consequences (4), and early surgery is not usually necessary as a lifesaving procedure.

Surviving the rupture of the both AV valves in blunt thoracic trauma is an uncommon event, making the diagnosis unlikely. We found only three similar cases in the literature (5–7) and one report in an autopsy series (8). The actual frequency of this type of cardiac injury is not known (9) and may be under-appreciated as a result of prehospital or early postadmission mortality and missed diagnoses.

Some authors have concluded that only patients with blunt chest trauma who develop cardiac complications benefit from echocardiography and that TEE is of value only when the transthoracic echocardiographic examination (TTE) is suboptimal or aortic injury is suspected (10). Others recommend that TEE should be routinely performed in all victims of violent deceleration collisions regardless of the presenting mediastinal profile on supine chest radiograph (1,11) or at least considered in the cases suspicious for heart injury (12).

The diagnostic superiority of the TEE has been established when compared to TTE (13–15), angiography (16) and helical CT (17). Most authors agree that TEE is an ideal tool to diagnose cardiac and aortic injury in the patient with blunt chest trauma because it provides high quality images of the heart and thoracic aorta and can be safely and rapidly performed in the emergency department, OR, or intensive care unit (18–20).

We conclude that this patient’s case not only presents an example of a rare consequence of blunt chest trauma but also adds further evidence to support the important utility of screening TEE in trauma. Because of the rushed emergent nature in which this unstable trauma patient presented to the OR with these surreptitious cardiac injuries present, it is almost certain that this patient’s outcome would have been fatal had a screening intraoperative TEE not been performed. We hope that this report will serve to reinforce to other anesthesiologists the possibility of similar intracardiac pathology in severely traumatized patients.

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References

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