Severe traumatic tricuspid insufficiency detected 10 years after blunt chest trauma

Abstract

A 29 years old male patient was found to have a systolic murmur on a routine medical examination. He was referred to a cardiologist for trans-thoracic echocardiography (TTE), which revealed a severe insufficiency of the tricuspid valve with a flail anterior leaflet due to complete rupture of a papillary muscle (Carpentier’s Type II dysfunction). The right ventricle was hypertrophic and dilated with a normal systolic function. There were no signs of pulmonary hypertension and the left ventricular ejection fraction was preserved (EF = 54%). The patient did not have any cardiovascular history such as myocardial ischemia, rheumatic fever or infective endocarditis. On the other hand, he mentioned to have had two severe car accidents 11 and 10 years ago. In detail, he suffered from two blunt, frontal chest traumas including multiple costal fractures and a clavicle fracture. Therefore, a traumatic injury of the tricuspid valve was highly suspected. In the further history, the patient denied any cardiac symptoms such as syncope, dyspnea, angina pectoris or palpitations, but reported occasional apical chest pains. The patient was referred to our tertiary center and was scheduled for surgical repair of the tricuspid valve. An intraoperative trans-esophageal echocardiography (TOE) confirmed the preoperative findings (Fig. 1a, b). The operation was performed via classical sternotomy under cardiopulmonary bypass with bicaval cannulation. After opening the right atrium, the rupture of the papillary muscle was confirmed and the anterior leaflet was massively extended. The anterior leaflet was re-fixed using six Gore-Tex sutures as artificial chordae (69 Gore-Tex 6-0 sutures) and was stabilized with a rigid annuloplasty ring (Physio 34 mm, Edwards Lifesciences, Irvine, USA). The intraoperative TOE revealed a successful repair of the valve without detectable insufficiency (Fig. 2a, b). The rest of the procedure was uneventful and the patient was referred to the ICU. After 1 day in the ICU and 5 more days in the normal ward, the patient was discharged and made a swift recovery. Three months after surgery, the patient was in good condition with no residual tricuspid regurgitation. We report a rare case of a severe tricuspid valve regurgitation following blunt chest trauma, which has remained asymptomatic and undetected for over 10 years. Posttraumatic tricuspid valve insufficiency is a rare occurrence, but due to its anterior location, it remains the most frequently reported valve injury following blunt chest trauma [1]. Major mechanisms for traumatic tricuspid valve injury include rupture of the papillary muscles, chordal disruption, free rupture of the valve leaflets or complete destruction of the valve [2]. Although there have been many advances in echocardiography, allowing a faster diagnosis and resulting in an earlier and more effective treatment, the diagnosis of traumatic tricuspid valve insufficiency is often delayed or even can be completely unrecognized,. Major reasons for this problem are the general rarity, the absence or inhomogeneity of symptoms and the presence of coexisting life-threatening injuries such as hemato-pneumothorax, which have to be treated with priority, obscuring other pathologies [3, 4]. For this reason, it is not exceptional for patients to present years after the trauma [5]. In our patient, M. Y. Emmert (&) R. Pretre S. Suendermann B. Weber S. P. Hoerstrup V. Falk Clinic for Cardiovascular Surgery, University Hospital Zurich, Raemi Street 100, 8091 Zurich, Switzerland e-mail: maximilian_emmert@web.de