EComment. Tricuspid valve and blunt chest trauma

Abstract

We read with interest the article by Thekkudan and associates regarding the tricuspid valve chordal rupture due to blunt injury and we agree with their comment that the timing of the surgical intervention in the heart valve depends on the patient's general clinical condition [1]. Cardiac valvular injuries are quite uncommon after blunt thoracic trauma and the tricuspid valve is perhaps the more vulnerable because of the proximity of the right ventricle to the sternum [2]. Bailey et al. have highlighted that even a moderate blunt chest injury can provoke a significant injury of cardiac valves [2]. The major causes of injury are related to motor vehicle accidents followed by falls from one or more stories, falls off a horse or bus and compressed air explosions [2, 3]. Van Son et al. have reported on their experience with the surgical management of thirteen patients with tricuspid insufficiency due to blunt chest trauma (twelve cases were related to motor vehicle accidents and one to an explosion of a tank of compressed air). The median duration between trauma and surgical treatment was 17 years (range, 1 month to 37 years) and the primary cause of tricuspid insufficiency was flail of the anterior leaflet because of chordae tendinea rupture (n = 9), rupture of anterior papillary muscle (n = 3), or tear in the anterior leaflet (n= 1). In one patient, the septal leaflet was missing and in another it was retracted and adherent to the ventricular septum. Eight patients underwent tricuspid valve replacement and four tricuspid valve repair. No early or late deaths occurred at a median follow-up of 12 years [3]. Choi and Kim have reported on the successful management of simultaneous rupture of mitral and tricuspid valve with left ventricular rupture due to blunt chest injury. Their brief review of the relevant literature found that only eight patients had simultaneous rupture of the atrioventricular valves [4]. The diagnostic and therapeutic approach is a real challenge for these complex cases. When cardiac trauma is suspected after blunt chest trauma, transthoracic echocardiography can facilitate its appropriate management. However, the atrioventricular valve rupture can be missed due to cardiac tamponade and resultant ventricular collapse or due to other significant thoracic injuries [4]. In controversial cases or in extremely unstable patients transesophageal echocardiography (preoperative and/or intraoperative) can establish the definitive diagnosis [2]. Post-traumatic tricuspid and mitral valve repair has to be considered very carefully because these patients are haemodynamically unstable and there are anatomic valvular difficulties such as myocardial contusion, focal endocardial ischaemia, friable endocardium and necrotic papillary muscle. Because the right heart is a low-pressure system and the septomarginal trabecula is thick, the ruptured anterior papillary muscle can be reattached to its primary position with the use of the native chordae or neochordae with pledgeted sutures [1, 4]. In conclusion, the experience of valve repair in blunt chest trauma is limited however, especially for the tricuspid valve this therapeutic modality can be effective.