Res Cardiovasc Med. 2014 August; 3(3): e17319.

DOI: 10.5812/cardiovascmed.17319 Case Report

Published online 2014 July 28.

Aortic Valve Injury Following Blunt Chest Trauma 1

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Maryam Esmaeilzadeh ; Hedieh Alimi ; Majid Maleki ; Saeid Hosseini

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1Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran 2Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran 3Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran

*Corresponding author: Hedieh Alimi, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel: +98-9155145632, Fax: +98-2122055594, E-mail: [email protected]

Received: January 1, 2014; Revised: February 25, 2014; Accepted: June 30, 2014

Introduction: Heart valve injury following blunt chest trauma of car accidents is increasing. Although aortic valve involvement is rare, however, in survivors of blunt cardiac trauma it is the most commonly involved valve and the most frequent valve lesion is isolated injury of the noncoronary cusp of aortic valve. Case Presentation: A 31-year-old man with a history of car accident (five months before) was referred to our clinic because of shortness of breath. A holo-diastolic blowing murmur was heard on physical examination. Transesophageal echocardiography demonstrated severe aortic insufficiency secondary to rupture of the left coronary cusp associated with avulsion of aortic valve commissure. Conclusions: Since the aortic valve is rarely affected in blunt cardiac injury, it will be generally undiagnosed during the primary evaluation of a patient with blunt chest trauma. However, any patient presenting dyspnea after chest trauma should be examined for suspected aortic valve injury. Keywords:Aortic Valve; Rupture; Aortic Valve Insufficiency; Echocardiography

1. Introduction Heart valve injury following blunt chest trauma is increasing, mostly as a result of car accidents. Aortic valve (AV) rupture after blunt chest trauma is not common. In a large autopsy series, out of 546 deaths due to blunt chest trauma only one case of an isolated AV injury was reported (1). Until late 1994, only 33 patients with AV rupture following blunt chest trauma have been reported (2-4). Although AV involvement is rare, however, in survivors of blunt cardiac trauma it is the most commonly involved valve (5). Traumatic AV regurgitation may be secondary to direct valve injury (i.e. ruptured leaflets) or following ascending aorta trauma with consequent AV prolapse (6). The most frequent valve lesion is isolated injury of the noncoronary cusp as a tear or an avulsion of the cusp or commissure (5). Here, we report a rare case of AV rupture and commissure avulsion, well visualized by multiplane transesophageal echocardiography, which was diagnosed five months after a car accident. The diagnosis was confirmed during surgery.

2. Case Presentation

A 31-year-old man, who was involved in a car accident several months ago and experiencing shortness of breath and paroxysmal nocturnal dyspnea, was referred to our institution for further evaluation.

On physical examination, blood pressure = 130/50 mm Hg, respiratory rate = 14 per minute, pulse rate = 78 beats per minute, temperature = 36.5°C and a grade III/VI systolic murmur and a holo-diastolic blowing murmur which radiated to the left lower sternal border were heard. Chest x-ray revealed cardiomegaly (Figure 1) and electrocardiogram revealed non-specific ST-T (ST segment and T wave) changes. Transthoracic echocardiography revealed severe left ventricular enlargement with mild to moderate systolic dysfunction (ejection fraction = 45%), moderate right ventricular enlargement and systolic dysfunction, moderate tricuspid regurgitation and severe pulmonary hypertension (pulmonary artery pressure = 75 mm Hg). Severe aortic regurgitation (multiple distinct jets) and two long regular-edged prolapsing mobile particles on the left coronary cusp (LCC) were noted which suggested a large tear along the LCC (Figure 2). Transesophageal echocardiography was done which showed a large oval shaped tear along the base of the LCC (Figure 3) resulting in severe regurgitation mostly from the torn LCC, however, additional regurgitant jets were also seen from the suspension point of LCC and right coronary cusp (avulsion of the commissure). There was substantial prolapse of the basal portion of the torn leaflet. The patient underwent cardiac surgery. During cardiopulmonary bypass with hypothermic anoxic arrest extensive tearing of the LCC was noted (Figure 4). Aortic valve was not repairable because of avulsion injury, so it was replaced by

Copyright © 2014, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences; Published by Kowsar. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Esmaeilzadeh M et al. a mechanical bileaflet valve. The post-operative course was uneventful. The patient's condition improved dramatically and he was discharged a week after the operation.

Figure 3. Transesophageal Echocardiograms

Figure 1. Chest Radiograph Showing Cardiomegaly and Interstitial Pulmonary Edema Figure 2. Transthoracic Echocardiograms

Transesophageal echocardiograms at 0 and 120 degrees show large tear of the left coronary cusp of the aortic valve (arrow) and avulsion of the free edge of the left coronary cusp; LCC: left coronary cusp.

Transthoracic echocardiograms show long regular-edged prolapsing mobile particles on the left coronary cusp (arrow) and massive aortic regurgitation by the color Doppler.

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Figure 4. Intraoperative View of the Left Coronary Cusp Rupture

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Esmaeilzadeh M et al.

3. Discussion Clinically, cardiac injury may be missed at the initial post-trauma assessment due to the lack of suspicion of cardiac involvement. Also, other coexistent injuries such as fractured ribs and pulmonary contusion with the same chief complaints may mask the manifestations of cardiac injury. The respiratory distress may prohibit auscultation of the heart. Thus the diagnosis of AV rupture is often delayed or missed for a time interval of days to months. The mechanism of non-penetrating rupture of the AV is believed to be a sudden increase of intra-thoracic pressure at the time of impact, particularly during early diastole when the pressure difference across the aortic valve is maximal (7). Although noncoronary cusp was the most torn leaflet that was found, yet multiple leaflets injury may coexist. Valve repair has been reported in a few cases (8), but avulsion-type valve injury makes primary repair difficult so valve replacement is the recommended operative procedure (7). In conclusion, in any patient after blunt chest

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trauma the possibility of cardiac valve injury including AV should be taken in to account.

References 1. 2. 3. 4. 5. 6. 7. 8.

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Aortic valve injury following blunt chest trauma.

Heart valve injury following blunt chest trauma of car accidents is increasing. Although aortic valve involvement is rare, however, in survivors of bl...
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