Copyright © 2005, The European Society of Cardiology
Acute traumatic disruption of a bicuspid aortic valve
ASL 4, Ospedale Giovanni Bosco, Divisione di Cardiologia, Piazza Donatore di sangue 3, 10100 Torino, Italy
Received 26 May 2005; received in revised form 23 July 2005; accepted after revision 3 August 2005.
* Corresponding author. Tel.: +39 0112402261; fax: +39 0112402375. monica.anselmino{at}fastwebnet.it
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Cardiac involvement is frequent in patients with blunt chest trauma and multiple injuries. Different cardiac structures can be involved, but isolated aortic valve rupture is rare. We report the case of a man admitted to our hospital with multiple injuries as a result of a car crash. Transthoracic, followed by transesophageal echocardiography, revealed disruption of a large anterior bi-coronary cusp in a bicuspid valve with severe aortic regurgitation, without lesions or abnormalities of thoracic aorta.
Aggressive pharmacological management consented to delay valve replacement to obtain resolution of concomitant pulmonary injuries.
Keywords: Aortic valve; Bicuspid valve; Traumatic rupture
A 60-year-old man was admitted to the emergency room after involvement in an automobile accident with high speed deceleration. On arrival he was unconscious. Physical examination revealed low systolic blood pressure (60mmHg) and a regular pulse rate of 110beats/min. Cranial, thoracic, abdominal and pelvic computed tomography showed bilateral pulmonary damage for contusion, with slight left pleural effusion and signs of infero-posterior bilateral lobar dysventilation, multiple left rib fractures, but a normal thoracic aorta. Soon after arrival a transthoracic echocardiography showed a slightly enlarged LV with preserved systolic function, no signs of myocardial contusion, abnormal excursion of one aortic valve cusp with suspected rupture and severe aortic regurgitation. The patient was then treated with intravenous diuretics and vasodilators obtaining rapid hemodynamic stabilization; blood pressure was maintained around 120/30mmHg with adequate diuresis, in absence of pulmonary edema. Surgical intervention was postponed until pulmonary injuries improved. Transesophageal echocardiography (TEE) showed a bicuspid aortic valve, with a very large cusp, occupying approximately 2/3 of the valvular circumference, including both the coronary ostia, and a smaller non-coronary cusp (Fig. 1). The bi-coronary cusp showed a profound laceration in front of the left main coronary, with partial eversion in the outflow tract (Figs. 2 and 3
) and consequent massive regurgitation. The thoracic aorta was normal. On post-injury day 7 the patient underwent successful aortic valve replacement with a St. Jude 23 prosthetic valve, and a subsequent favourable course. Surgical findings confirmed the anatomical aspects described with TEE, and a normal thoracic aorta.
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Severe aortic regurgitation is a rare complication of non-penetrating chest trauma. Most cases occur in association with injuries of thoracic aorta, while aortic valve isolated lesions are very rare.1 The mechanism of rupture is thought to be the steep rise of intrathoracic pressure at the time of impact and thoracic compression, when the valve is closed in diastole.2 Bicuspid aortic valve ruptures are only exceptionally described3; this structural anomaly could be responsible of increased valve susceptibility to injuries, but there is no objective evidence to support this hypothesis.
In this case the damaged bi-coronary cusp presented an unusual extension along 2/3 of annulus circumference that may have favoured a greater tension on its free edge at the time of external chest compression.
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References |
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- Meunier J.P., Berkane N., Lopez S., Sicart-Toulouse C., Malzac B., Isetta C., et al. Traumatic aortic regurgitation: diagnostic, management and treatment. Arch Mal Coeur Vaiss (2004) 97(6):613–618.[Web of Science][Medline]
- Pretre R., Faidutti B. Aortic valve rupture in closed trauma: the extent of the damage. J Thorac Cardiovasc Surg (1993) 106:371–373.[Web of Science][Medline]
- Tokizawa N., Ishikawa S., Takahashi T., Otaki A., Otani K., Morishita Y. Surgical treatment of traumatic rupture of the bicuspid aortic valve: case report. Nippon Kyobu Geka Gakkai Zasshi (1994) 42(1):74–77.[Medline]
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