Case Reports in Cardiology

Case Reports in Cardiology / 2020 / Article

Case Report | Open Access

Volume 2020 |Article ID 8505894 | https://doi.org/10.1155/2020/8505894

Ruchika Meel, Bongane Ngutshane, Ricardo Gonçalves, Shungu Mogaladi, "A Case of Severe Tricuspid Regurgitation Related to Traumatic Papillary Muscle Rupture", Case Reports in Cardiology, vol. 2020, Article ID 8505894, 5 pages, 2020. https://doi.org/10.1155/2020/8505894

A Case of Severe Tricuspid Regurgitation Related to Traumatic Papillary Muscle Rupture

Academic Editor: Man-Hong Jim
Received29 Sep 2019
Accepted19 Mar 2020
Published31 Mar 2020

Abstract

A 25-year-old male presented after a motor vehicle accident with tricuspid valve (TV) regurgitation, due to a flail TV secondary to papillary muscle rupture. We highlight the importance of three-dimensional echocardiographic imaging of the tricuspid valve and its utility in aiding a successful surgical repair.

1. Introduction

The majority of injuries to the tricuspid valve (TV) apparatus are related to blunt chest trauma [1]. Motor vehicle accidents (MVA) are a common cause of blunt trauma to the heart. It is unusual for the TV to be involved in isolation [24]. The aortic valve is most commonly involved, followed by the mitral valve and finally the TV. The postulated mechanism of injury to the TV in these cases tends to be a rapid deceleration force combined with an increase in intracardiac right chamber pressures [5]. In a vast number of cases of MVA, cardiac injury tends to be overlooked due to other overt injuries [6]. Injury to the TV can be silent depending on the severity of structural damage [7]. Therefore, some authors have advocated routine and timeous use of echocardiography in patients sustaining blunt trauma to the chest [6]. The advent of newer echocardiographic techniques such as three-dimensional (3D) imaging acts as a supplementary tool in characterising the precise location of injury to the TV [8].

2. Case Presentation

A 25-year-old healthy male presented to a peripheral hospital in Johannesburg, South Africa, after an MVA. He was an unrestrained passenger who hit the car dashboard after sudden deceleration from high speed. He sustained multiple injuries including bilateral hemopneumothoraxes. An admission transthoracic echocardiogram (TTE) revealed severe TR of unclear mechanism.

He was referred 2 weeks after the index admission to a tertiary hospital. On arrival, he was asymptomatic and haemodynamically stable. He had abrasion marks on the chest (Figure 1). Cardiovascular examination revealed prominent internal jugular vein c-v waves and a soft grade 2/6 pansystolic murmur at the left lower parasternal border. He was not in heart failure. Sinus tachycardia and an early repolarisation pattern were noted on the 12-lead electrocardiogram. He had normal laboratory blood parameters. On TTE, a moderately enlarged right ventricle (RV) and right atrium, with preserved RV systolic function, was noted. There was a flail TV leaflet and an oscillating mass in the right atrium (Figure 2(a)). Avulsion of the anterior papillary muscle from the RV wall was suspected. The colour flow Doppler revealed severe TR with an early peaking triangular jet velocity of 2.16 m/sec (Figures 2(b) and 3(a)). There was systolic flow reversal in the hepatic veins (Figure 3(b)). A 3D transoesophageal echocardiogram (TEE) was performed which confirmed a flail anterior TV leaflet due to rupture of the anterior papillary muscle (Figures 4(a), 5(a), and 5(b)). On 3D colour flow, the TR was severe, with the jet filling greater than 50% of the right atrium (Figure 4(b)).

The patient underwent a successful surgical repair of the TV (Figure 6). A flail anterior TV leaflet due to anterior papillary muscle rupture was identified with a residual papillary muscle stump on the RV. The anterior papillary muscle was reattached to the stump with pledgeted 4-0 polypropylene sutures. Additionally, a modified De Vega annuloplasty was done. Finally, the valve competency was tested by saline injection into the RV and confirmed by TEE after coming off cardiopulmonary bypass. Trivial TR was noted. The patient had an uneventful postoperative course.

3. Discussion

Our case brings attention to the following pertinent aspects related to traumatic tricuspid valve insufficiency: (1) underreporting of TV injury in Africa and the importance of meticulous screening for TV injury in patients with history of blunt chest trauma; (2) the value of three-dimensional imaging of the TV prior to surgical referral; and (3) early referral for surgery of patients with severe TR due to TV injury.

Motor vehicle accidents are an important cause of TV injury [9, 10]. South Africa has one of the highest motor vehicle accident-related fatalities [11, 12]. Yet, there is a paucity of data regarding TV trauma related to MVA. This is possibly due to TV injuries being missed in a polytrauma patient, lack of resources in terms of imaging in low- and middle-income countries, or underutilisation of existing imaging modalities due to a lack of expertise. Additionally, the true prevalence of TV regurgitation due to trauma is underreported as patients experience minimal or no symptoms for a prolonged period of time [13]. TTE is a useful bedside tool for assessing cardiac structure and function in a trauma patient [14]. It is freely available at most institutions, noninvasive, inexpensive, and radiation- and contrast-free [15]. It has been validated as a useful tool for right heart, TV, and subvalvular apparatus assessment. Transoesophageal echocardiography (TEE) can be utilised in cases where TTE provides insufficient information for decision making14. However, TEE is not widely available and needs specialized expertise.

Recently, more attention has been focused on 3-dimensional imaging of the TV [16]. It allows “enface” views of the valve and thus easy discrimination of the 3 TV leaflets. Accurate anatomical information aided in planning this TV repair by identifying the exact site anterior papillary muscle rupture. The literature suggests a lower success rate for surgical repair when the mechanism for TV regurgitation is not papillary muscle rupture [13]. In the current era of 3D imaging, successful TV repair for TR due to papillary muscle rupture has been reported [17].

A surgeon with sufficient skill and experience in repairing tricuspid valves is crucial, and all imaging is complementary to direct anatomical inspection. Early referral of patients with severe TR is advised to prevent right ventricular dysfunction from chronic volume overload [13]. It has been noted that if the operation is delayed, valve repair becomes more challenging due to the development of fibrosis of the valve and subvalvular apparatus [18]. For these reasons, early surgical referral was preferred and led to a successful outcome. Follow-up of the patient is important as TR may recur.

In conclusion, we have presented a case of successful TV repair with the aid of 3D echocardiographic imaging from Africa. We hope that this case will stimulate readers to actively search for and report on TV-related injury in a patient with a history of chest trauma.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The first author is the recipient of postdoctoral Carnegie fellowship award.

References

  1. G. Avegliano, M. Corneli, D. Conde, and R. Ronderos, “Traumatic rupture of the tricuspid valve and multi-modality imaging,” Cardiovascular diagnosis and therapy, vol. 4, no. 5, pp. 401–405, 2014. View at: Publisher Site | Google Scholar
  2. L. F. Parmley, W. C. Manion, and T. W. Mattingly, “Nonpenetrating traumatic injury of the heart,” Circulation, vol. 18, no. 3, pp. 371–396, 1958. View at: Publisher Site | Google Scholar
  3. A. Cordovil, C. H. Fischer, A. C. T. Rodrigues et al., “Papillary muscle rupture after blunt chest trauma,” Journal of the American Society of Echocardiography, vol. 19, no. 4, pp. 469.e1–469.e3, 2006. View at: Publisher Site | Google Scholar
  4. M. Pasquier, C. Sierro, B. Yersin, D. Delay, and P. N. Carron, “Traumatic mitral valve injury after blunt chest trauma: a case report and review of the literature,” The Journal of Trauma, vol. 68, no. 1, pp. 243–246, 2010. View at: Publisher Site | Google Scholar
  5. S. Sbar and E. E. Harrison, Chronic tricuspid insufficiency due to trauma. The Heart: Update III, McGraw-Hill, New York, 1980.
  6. S. Khurana, R. Puri, D. Wong et al., “Latent tricuspid valve rupture after motor vehicle accident and routine echocardiography in all chest-wall traumas,” Texas Heart Institute Journal, vol. 36, no. 6, pp. 615–617, 2009. View at: Google Scholar
  7. B. Stoica, S. Paun, I. Tanase, I. Negoi, A. Runcanu, and M. Beuran, “Traumatic Tricuspid Valve Rupture after Blunt Chest Trauma - A case Report and Review of the Literature,” Chirurgia, vol. 110, no. 5, pp. 467–470, 2015. View at: Google Scholar
  8. I. Stankovic, A. M. Daraban, R. Jasaityte, A. N. Neskovic, P. Claus, and J. U. Voigt, “Incremental value of the en face view of the tricuspid valve by two-dimensional and three-dimensional echocardiography for accurate identification of tricuspid valve leaflets,” Journal of the American Society of Echocardiography, vol. 27, no. 4, pp. 376–384, 2014. View at: Publisher Site | Google Scholar
  9. G. Dounis, E. Matsakas, J. Poularas, K. Papakonstantinou, A. Kalogeromitros, and A. Karabinis, “Traumatic tricuspid insufficiency: a case report with a review of the literature,” European Journal of Emergency Medicine, vol. 9, no. 3, pp. 258–261, 2002. View at: Publisher Site | Google Scholar
  10. C. L. Jiang, T. X. Gu, Z. W. Zhang, and Z. Y. Xiu, “Diagnosis and treatment of traumatic tricuspid valve insufficiency,” Chinese Journal of Traumatology, vol. 6, no. 6, pp. 379–381, 2003. View at: Google Scholar
  11. N. B. Moodley, C. Aldous, and D. L. Clarke, “An audit of trauma-related mortality in a provincial capital in South Africa,” South African Journal of Surgery, vol. 52, no. 4, pp. 101–104, 2014. View at: Publisher Site | Google Scholar
  12. “Accident crash statistics – arrive alive,” February 2019, https://www.arrivealive.mobi/accident-crash-statistics. View at: Google Scholar
  13. F. Maisano et al., “Valve repair for traumatic tricuspid regurgitation,” European Journal of Cardio-Thoracic Surgery, vol. 10, no. 10, pp. 867–873, 1996. View at: Publisher Site | Google Scholar
  14. S. J. Co, C. J. Yong-Hing, S. Galea-Soler et al., “Role of imaging in penetrating and blunt traumatic injury to the heart,” Radiographics, vol. 31, no. 4, pp. E101–E115, 2011. View at: Publisher Site | Google Scholar
  15. A. Kossaify, “Echocardiographic assessment of the right ventricle, from the conventional approach to speckle tracking and three-dimensional imaging, and insights into the “right way” to explore the forgotten chamber,” Clinical Medicine Insights: Cardiology, vol. 9, pp. 65–75, 2015. View at: Publisher Site | Google Scholar
  16. D. Muraru, R. T. Hahn, O. I. Soliman, F. F. Faletra, C. Basso, and L. P. Badano, “3-dimensional echocardiography in imaging the tricuspid valve,” JACC: Cardiovascular Imaging, vol. 12, no. 3, pp. 500–515, 2019. View at: Publisher Site | Google Scholar
  17. K. Nishimura, H. Okayama, K. Inoue et al., “Visualization of traumatic tricuspid insufficiency by three-dimensional echocardiography,” Journal of Cardiology, vol. 55, no. 1, pp. 143–146, 2010. View at: Publisher Site | Google Scholar
  18. J. A. M. van Son, G. K. Danielson, H. V. Schaff, and F. A. Miller Jr., “Traumatic tricuspid valve insufficiency: Experience in thirteen patients,” The Journal of Thoracic and Cardiovascular Surgery, vol. 108, no. 5, pp. 893–898, 1994. View at: Publisher Site | Google Scholar

Copyright © 2020 Ruchika Meel et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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