Traumatic Tricuspid Insufficiency Research Articles

Abstract 17742: Anterior Papillary Muscle Rupture After a Motor Vehicle Collision: A Rare Case of Torrential Tricuspid Regurgitation After Blunt Cardiac Injury

Introduction: Blunt cardiac injury is difficult to diagnose in the setting of polytrauma. Here we present a rare case of a torrential tricuspid regurgitation from a ruptured anterior papillary muscle after a motor vehicle collision (MVC). Case: A 55-year-old male presented to the ED after an MVC. He was hemodynamically unstable and hypoxic en route complaining of severe chest and left leg pain. Imaging demonstrated multiple rib fractures, a left acetabular fracture, and left open distal femur fracture. EKG identified atrial fibrillation with RVR and nonspecific ST changes. Labs were significant for leukocytosis and a troponin elevation to 11.98 concerning for blunt cardiac injury. A TTE demonstrated a mobile density in the RA and RV consistent with papillary muscle rupture and severe tricuspid regurgitation. An underfilled left ventricle compressed by the right heart and dilated RV were noted with septal flattening consistent with RV pressure and volume overload. Cardiothoracic surgery was consulted and recommended delayed tricuspid valve repair after other acute injuries were addressed considering the need for full anticoagulation. While in the ICU, his orthopedic injuries were addressed though his hemodynamics were complicated by frequent orthopedic interventions requiring blood transfusions. He later underwent TV replacement and it was found that the anterior papillary muscle was ruptured at its base without leaflet perforation. One week post-operatively the patient suffered a hypoxic PEA arrest. The shock team was consulted and he underwent bedside ECMO cannulation with impella placement for LV failure. After ten days on ECMO he was decannulated. Ultimately, the patient recovered well and was discharged to acute rehab. Discussion: MVCs are a leading cause of traumatic tricuspid insufficiency. However, this life-threatening condition may go undetected due polytrauma and the presence of coexisting distracting injuries. Guidelines are needed for the specific management of traumatic tricuspid regurgitation and associated right heart dysfunction. Additionally, the need for multiple surgical interventions can preclude anticoagulation which is a unique barrier to urgent valve replacement in these patients.

Midterm outcomes of surgical treatment of traumatic severe tricuspid insufficiency

Objective: To investigate the indication and midterm outcomes of surgical treatment of traumatic tricuspid insufficiency. Methods: Totally 19 patients with traumatic tricuspid insufficiency who underwent surgical treatment at Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University from January 2002 to January 2018 were included in this retrospective study. There were 12 male and 7 female patients, aged (43.1±12.9) years (range: 17-68 years). The main causes of traumatic tricuspid insufficiency included blunt chest trauma following high-speed vehicle accidents (17 patients) and high-fall trauma (2 patients). The preoperative New York Heart Association functional class was class Ⅱ in 5 patients, class Ⅲ in 12 patients, and class Ⅳ in 2 patients. The mechanism of tricuspid insufficiency included anterior chordal rupture in 9 patients, anterior papillary muscle rupture in 3 patients, anterior and posterior chordal or papillary muscle rupture in 4 patients, laceration of leaflet combined with chordal rupture in 2 patients and infection combined with anterior papillary muscle rupture in 1 patient. Anular dilation and enlargement of the right ventricle were observed in all the patients. Paired t test was used to evaluate the echocardiogratic results at preoperation, postoperation and follow-up. Independent sample rank sum test was used to evaluate the intervals between trauma and surgery in tricuspid valve repair group and tricuspid valve replacement group. Results: Tricuspid valve repair was successful in 8 patients, and 11 patients underwent valve replacement. Among the patients who underwent valve replacement, 6 patients received mechanical valve and 5 received bioprosthetic valve. The interval from trauma to surgery of the valve repair group and valve replacement group were 8.5(10.0) months (range: 0.1-13.0 months) and 72.0 (108.0) months (range: 2.0-228.0 months), respectively. Concomitant procedures included debridement in scalp trauma (1 patient), internal fixation of femoral fracture (1 patient). One patient died from liver failure 10 days after operation and the remaining patients survived. Eighteen patients were followed up for (94±50) months, 15 patients were in New York Heart Association functional class Ⅰ and 3 patients in class Ⅱ. One patient received redo-tricuspid valve replacement because of mechanical valve failure at the 11 years of follow-up. Conclusions: The midterm outcomes of surgical treatment of severe traumatic tricuspid insufficiency were satisfactory. Early diagnosis and surgical invention were recommended to achieve successful valve repair.

Surgical management of traumatic tricuspid insufficiency.

This study reviews our experience with traumatic tricuspid insufficiency (TTI) following blunt chest trauma. From January 2010 to June 2016, 10 patients (nine males, mean age 49.0 ± 12.4 years) underwent surgical treatment of TTI following blunt chest trauma. The mean intervals between trauma and diagnosis and between trauma and surgery were 74.1 and 81.8 months, respectively. Preoperatively, all patients exhibited severe tricuspid regurgitation. Five patients underwent tricuspid valve repair, and the remaining patients underwent valve replacement. The mean follow-up duration (with echocardiography) was 29.7 months. There was no early or late death. Seven patients had anterior chordal rupture, two patients had anterior papillary muscle rupture, and one patient had both anterior chordal and anterior leaflet rupture. The median postoperative intensive care unit and hospital stays were 1 and 6 days, respectively. There were no severe postoperative complications. During follow-up, four patients exhibited trivial to mild tricuspid regurgitation, and the remaining six patients exhibited no regurgitation. Surgical treatment of TTI via either valve repair or replacement can be performed with low perioperative morbidity and mortality. Early surgery is recommended for achieving a successful valve repair and preserving right ventricular function.

Repair of Tricuspid Insufficiency Following Blunt Trauma Chest - A Case Report and Review of Literature

Tricuspid incompetence after blunt chest trauma is uncommon and is most often associated with traffic accidents. The signs of traumatic tricuspid insufficiency can be appear early or delayed, depending upon the severity of injury. We present the case of a young male who had severe tricuspid regurgitation due a blunt chest trauma in an automobile collision and underwent successful repair.

Acute Repair of Traumatic Tricuspid Valve Regurgitation Aided by Three-Dimensional Echocardiography

A 54 year-old man without prior cardiac history was involved in a motor vehicle accident. His heart rate was 100/min and blood pressure 128/78 mmHg. He complained of anterior chest pain, and on examination had a loud pan-systolic murmur with no clinical signs of heart failure. Three-dimensional trans-oesophageal echocardiography (3D-TOE) demonstrated partial rupture of the inferior head of the anterior papillary muscle (when 2D-TOE did not), causing severe tricuspid regurgitation. This was successfully repaired. Tricuspid valve insufficiency is a rare, but well documented, complication of blunt chest trauma. The majority of cases of tricuspid regurgitation caused by blunt trauma are diagnosed and treated late after the traumatic event. Acute diagnosis is less common but possible with a high level of vigilance, and is greatly aided by clinical indicators of cardiac injury. We describe a case of acute repair of traumatic tricuspid insufficiency, in which diagnosis and surgical planning were greatly aided by 3D-TOE.

Surgical Treatment of Traumatic Tricuspid Insufficiency: Experience in 13 Cases

Traumatic tricuspid insufficiency (TTI) is uncommon and surgical experience is limited. We report our surgical experience with TTI in 13 patients. From January 2000 through March 2008, we operated on 13 patients with TTI (10 men 3 women; mean age, 39.8 ± 10.5 years). The intervals from trauma to diagnosis and from trauma to surgery averaged 37.4 and 54.4 months, respectively. At operation, the mechanism of TTI was due to anterior chordal rupture in 8, anterior papillary muscle rupture in 3, rupture of anterior papillary muscle and chordae in 1, and anterior leaflet defect in 1. In 7 patients the annulus was dilated. Valve repair was successful in 13 patients. No early or late deaths occurred. Severe hemolysis occurred in 1 patient after tricuspid and mitral valve repairs. At follow-up extending to 9.5 years, 9 patients were in New York Heart Association functional class I, and 4 were in class II. Transthoracic echocardiography demonstrated no or trivial residual regurgitation in 7 patients, mild regurgitation in 4, and mild-to-moderate regurgitation in 2. A significant decrease of the right ventricular end-diastolic dimension (37.7 ± 9.7 vs 20.7 ± 4.6 mm; p < 0.001) was observed. The mean transvalvular gradient was 2.5 ± 0.8 mm Hg. Eleven patients were in sinus rhythm. Satisfactory early and midterm outcomes can be achieved for TTI by tricuspid valve repair. Early surgical intervention should be emphasized to achieve good functional results and preserve the right ventricular function.

Severe traumatic tricuspid insufficiency detected 10 years after blunt chest trauma

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

Repair of traumatic tricuspid insufficiency via minimally invasive port access

We report on a successful tricuspid valve plasty using port-access minimally invasive cardiac surgery (MICS) for severe traumatic tricuspid insufficiency caused by blunt chest trauma suffered 15 years previously. A combination repair procedure, consisting of cleft closures, plication of the anteroseptal commissure, and ring annuloplasty, was necessary to achieve valve competence and proved possible via port access without difficulty. Port-access MICS is an alternative approach for tricuspid valve surgery.

Traumatic Tricuspid Insufficiency with Intact Chordae and Papillary Muscles: A Case Report

Traumatic Tricuspid Insufficiency with Intact Chordae and Papillary Muscles: A Case Report

Visualization of traumatic tricuspid insufficiency by three-dimensional echocardiography

A 19-year-old male was admitted to the emergency room of our hospital after a motor vehicle accident. During his first physical examination, a holosystolic murmur was heard at the fourth left parasternal border. Transthoracic echocardiography showed severe tricuspid insufficiency, but the cause of tricuspid insufficiency was unclear. Therefore, three-dimensional echocardiography was performed and demonstrated flail anterior, posterior and septal leaflets of the tricuspid valve. The diagnosis was tricuspid insufficiency due to papillary muscle rupture secondary to chest blunt trauma. Surgical repair of the tricuspid valve was performed in this patient. After surgery, the signs and symptoms of right ventricular heart failure were relieved. In this case, three-dimensional echocardiography was very useful for the evaluation of spatial destruction of the tricuspid valve and papillary muscle.

Traumatic Tricuspid Insufficiency with Chordae Tendinae Rupture: A Case Report and Literature Review

With the increase in the number of automobile accidents, traumatic tricuspid insufficiency, a rare complication of non-penetrating blunt chest injury, has become an important problem. This kind of injury has been found more frequently during the last decade, partly because of better diagnostic procedures and a better understanding of the pathology. Here, we report a 22-year-old male patient who suffered chest trauma from an automobile accident. Echocardiography demonstrated tricuspid chordae tendinae rupture with remarkable tricuspid regurgitation. We discuss this case in comparison with the previous literature. This case reminds us that physicians in the emergency department should be aware of this potential complication following non-penetrating chest trauma.

Correction of Traumatic Tricuspid Insufficiency Using the Double Orifice Technique

Traumatic tricuspid insufficiency is an uncommon clinical condition and surgical procedures vary. In this paper we report our experience in treating traumatic tricuspid insufficiency using the double orifice technique. From January 2000 to September 2003, 10 patients with traumatic tricuspid regurgitation were admitted to our hospital, 5 of whom were corrected using the double orifice technique. There were 4 males and 1 female with ages ranging from 31 to 52 years. Preoperative transthoracic echocardiography (TTE) detected severe tricuspid regurgitation in 4 patients and moderate tricuspid regurgitation in 1 patient. At surgery, tear of the tricuspid anterior papillary muscle was found in 2 cases and anterior chordal rupture in 3 cases. The valves were successfully repaired using the double orifice technique in combination with ring annuloplasty. There was no repeat operation, no operative complications or deaths. Before discharge, TTE detected normal tricuspid valve function in 2 cases and tiny regurgitation in 3 cases. After a follow up of 8 to 36 months, TTE demonstrated normal valve function in 1 patient and tiny regurgitation in 4 patients. The double orifice technique appears to be a simple but effective method of repairing traumatic tricuspid incompetence. Satisfactory clinical outcomes can be produced in carefully selected patients.

Blunt Chest Trauma - Equestrian Sports

History A 29-year-old elite dressage athlete experienced a blunt chest trauma due to a horsekick against her left lateral chest when crossing the horse backwards. Within the next 12 months after the horsekick she experienced progressive shortness of breath at exertion. Furthermore she complained of abdominal discomfort and swollen ankles. Physical examination Examination revealed hepatomegaly, jugular vein pulsation, and a new onset systolic murmur. Furthermore, she complained of tenderness at the left lateral chest. Differential diagnosis After a blunt chest trauma: Rip fracture Lung contusion Contusio cordis Heart valve endocarditis Structural heart valve defects Test and results Electrocardiography revealed a new complete right bundle branch block which was absent on previous ECG's performed before the horsekick. Ultrasound of the abdomen confirmed hepatomegaly with dilated hepatic veins. Transesophageal echocardiography showed a ruptured anterior leaflet of the tricuspid valve with a marked systolic reflux to the hepatic veins and severe right-sided cardiomegaly with no further structural cardiac defects, signs of endocarditis or wall motion abnormalities. Final diagnosis Traumatic tricuspid insufficiency Treatment and outcome: Cardiac surgery was performed. Following median sternotomy and after initiation of cardiopulmonary bypass with bicaval and aortal canulation, the right atrium was opened and the tricuspid region was examined, which revealed the isolated rupture of the septal papillary muscle. Neither further abnormalities of the valvular apparatus nor myocardial defects which may reveal an ischemic origin of the ruptured septal papillary muscle were seen in the operation. The septal papillary muscle was reattached with two PTFE-sutures. Furthermore, an annuloplasty was performed by an open annuloplasty Duran 31mm ring. The patient recovered early and uneventful. At follow-up 18 months after the procedure, she remained asymptomatic without any exercise restriction and again performing equestrian sports on an elite level.

Blunt Chest Trauma - Equestrian Sports

History A 29-year-old elite dressage athlete experienced a blunt chest trauma due to a horsekick against her left lateral chest when crossing the horse backwards. Within the next 12 months after the horsekick she experienced progressive shortness of breath at exertion. Furthermore she complained of abdominal discomfort and swollen ankles. Physical examination Examination revealed hepatomegaly, jugular vein pulsation, and a new onset systolic murmur. Furthermore, she complained of tenderness at the left lateral chest. Differential diagnosis After a blunt chest trauma: Rip fracture Lung contusion Contusio cordis Heart valve endocarditis Structural heart valve defects Test and results Electrocardiography revealed a new complete right bundle branch block which was absent on previous ECG's performed before the horsekick. Ultrasound of the abdomen confirmed hepatomegaly with dilated hepatic veins. Transesophageal echocardiography showed a ruptured anterior leaflet of the tricuspid valve with a marked systolic reflux to the hepatic veins and severe right-sided cardiomegaly with no further structural cardiac defects, signs of endocarditis or wall motion abnormalities. Final diagnosis Traumatic tricuspid insufficiency Treatment and outcome: Cardiac surgery was performed. Following median sternotomy and after initiation of cardiopulmonary bypass with bicaval and aortal canulation, the right atrium was opened and the tricuspid region was examined, which revealed the isolated rupture of the septal papillary muscle. Neither further abnormalities of the valvular apparatus nor myocardial defects which may reveal an ischemic origin of the ruptured septal papillary muscle were seen in the operation. The septal papillary muscle was reattached with two PTFE-sutures. Furthermore, an annuloplasty was performed by an open annuloplasty Duran 31mm ring. The patient recovered early and uneventful. At follow-up 18 months after the procedure, she remained asymptomatic without any exercise restriction and again performing equestrian sports on an elite level.

Traumatic tricuspid valve insufficiency

From 1964 through June 1993, thirteen patients with traumatic tricuspid insufficiency were treated surgically; all were male, and the ages ranged from 17 to 64 years (median 39 years). The condition was associated with blunt chest trauma in all patients: motor vehicle accidents in twelve and an explosion of a tank of compressed air in one. The median duration between trauma and operation was 17 years (range 1 month to 37 years). Preoperatively, six patients were in sinus rhythm and seven were in atrial fibrillation. At operation, the right ventricular function appeared moderately to severely depressed in twelve patients. In twelve patients, the anterior leaflet was flail because of chordal 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. In five patients the tricuspid valve was repaired and in eight it was replaced. In seven patients in the latter group, the chordae, papillary muscles, and/or tricuspid valve leaflet(s) were found to be in a contracted and atrophic state, precluding repair. No early or late deaths occurred. At follow-up extending to 26 years (median 12 years), 12 patients are in New York Heart Association class I and one patient is in class II. Nine patients were in sinus rhythm and four were in atrial fibrillation. Although our experience indicates that good functional results can still be achieved many years after the onset of traumatic tricuspid valve insufficiency, earlier diagnosis and surgical treatment should increase the feasibility of tricuspid valve insufficiency, earlier diagnosis and surgical treatment should increase the feasibility of tricuspid valve repair, prevent progressive deterioration of right ventricular function, and increase the possibility of maintaining late sinus rhythm in a greater number of patients.

Highly Acute Course of Ruptured Papillary Muscle of the Tricuspid Valve in a Case of Blunt Chest Trauma

The sudden onset of tricuspid insufficiency following a blunt chest trauma is extremely rare. We operated on a young woman in a state of severe shock following a riding accident, in whom complete severing of the papillary muscle of the posterior tricuspid leaflet had occurred. The valvuloplasty operation itself and the postoperative course ran smoothly, apart from a late pericardial tamponade which required surgical revision. In accordance with other reported cases we believe that traumatic tricuspid insufficiency is still a very underestimated pathological occurrence. Echocardiographic examination should therefore be regarded as an essential standard procedure in all cases of blunt chest injury.

Repair of Traumatic Ventricular Septal Defect and Associated Tricuspid Insufficiency: A Case Report

Penetrating cardiac trauma often results in serious and life-threatening sequelae. Traumatic ventricular septal defect and valvular insufficiency are among the rarest. The author presents a case of a young man who sustained cardiac arrest from ventricular tamponade secondary to a penetrating left ventricular stab wound. This patient was successfully resuscitated after open manual massage. A significant ventricular septal defect and associated tricuspid regurgitation were detected on the following day. Serial echocardiograms were used to evaluate the evolution of these two hemodynamic defects. The patient underwent operative repair for patch closure of a defect the size of a quarter and repair of the associated tricuspid papillary muscle dysfunction. His pulmonary status and right ventricular failure improved with resolution of his ascites. The operative and medical considerations are discussed for these unique traumatic intracardiac defects.

A Case of Traumatic Tricuspid Insufficiency

A Case of Traumatic Tricuspid Insufficiency

Traumatic Tricuspid Insufficiency: An Underdiagnosed Disease

Twelve cases of traumatic tricuspid insufficiency (only three of which already have been published), collected in the same city, are reported. This figure strongly contrasts with the limited number of cases published to date in the literature. Emphasis is placed on the difficulty of diagnosis, the utility of echocardiography and Doppler ultrasound and therapeutic problems of this lesion.

Tricuspid Insufficiency Caused by Nonpenetrating Chest Trauma

Two cases of traumatic tricuspid insufficiency are presented. Both patients followed a benign clinical course although an associated injury to the intraventricular septum was found in one. A flail anterior tricuspid leaflet was seen on two-dimensional echocardiography in both patients and the diagnosis was confirmed by Doppler cardiography.