Traumatic aorto-right atrial fistula and tricuspid valve rupture. Post-operative cardiac and respiratory support with extracorporeal membran
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a CHU de Reims, Hpital Robert Debre, Service de Chirurgie Thoracique et Cardiovasculaire, Centre Hospitalier Regional et Universitaire, avenue du General Koenig, 51092-Reims Cedex, France
b Service de Chirurgie Thoracique et Cardiovasculaire, Hpital Jean-Minjoz, Boulevard Fleming, 25000 Besanon, France
Abstract
We report the case of a 30-year-old man admitted for a crushed chest trauma. The echocardiography found an aorto-right atrial fistula, a tricuspid valve rupture and a myocardial contusion. The fistula was closed using an autologous pericardial patch and a bioprosthetic tricuspid valve replacement was performed because the lesions did not allow for any valvular sparing. Because of the proximity between the right coronary ostium and the rupture, a venous aorto-right coronary bypass was performed. The ostium was also closed by the pericardial patch. A peripheral ECMO was implanted at the end of the surgical repair because of a right ventricle dysfunction and a respiratory failure related to severe bilateral pulmonary contusions. A few days later, renal, hepatic and coagulation failures were also noticed, justifying hemodialysis and transfusions. Despite an initial worsening of these five organ failures, the outcome was finally favorable and the patient was discharged 108 days after surgery. A 3-year follow-up revealed a complete recovery of all organ failures. To conclude, we firmly believe that the ECMO can be successfully applied in selected cases of severe right ventricular dysfunction and respiratory failure after cardiac surgery.
Key Words: Aortic root; Atrium; Trauma; Circulatory assistance temporary; Tricuspid valve; Rupture
1. Introduction
Chest traumas during road accidents are frequent and justify a detailed clinical examination. We report the case of a 30-year-old man, admitted for a chest crushing with severe cardiac and pulmonary lesions caused by a twelve-ton truck leading to a multiple organ failure treated by a post-operative ECMO implantation.
2. Clinical case
The thoracic examination found a transversal hematoma and multiple cardiac rubs. The chest X-ray revealed bilateral pulmonary contusions, rib fractures and a mediastinal enlargement. The echocardiography showed a rupture of the right aortic Valsalva's sinus into the right atrium and a large tricuspid insufficiency (Fig. 1). The ECG revealed a complete traumatic atrio-ventricular block.
A surgical repair was performed by sternotomy under extracorporeal circulation. The initial pericardial examination found no effusion or localized hematoma but a hypokinetic right ventricle. Using aortic and right atrial accesses, the Valsalva's sinus rupture was repaired with a pericardial patch fixed in glutaraldehyde, and a bioprosthetic tricuspid valve (Perimount from Carpentier–Edwards) was implanted because of the important valvular lesions. The right coronary ostium was closed and a venous aorto-right coronary bypass was performed, due to the proximity between the ostium and the rupture (Fig. 2).
At the end of the surgical repair, the right ventricle traumatic dysfunction worsened. As a result, the extracorporeal circulation weaning was impossible. The rapid implantation of a femoro-femoral extracorporeal membrane oxygenation (ECMO) support allowed for an increased cardiac flow close to 4.5 l/min. This ECMO, used at this time in our department, was built using a heparin bonded circuit of extracorporeal circulation from Medtronic with a Biomedicus pump and a classical fiber oxygenator.
The intravenous heparin therapy was continued for the full duration of the assistance allowing a partial thromboplastin time between 2.5 and 3 times the control value and the artificial ventilation was adapted using small insufflation volumes, low respiratory frequency and a moderate positive end-expiratory pressure of 5 cmH2O.
At post-operative day 2, renal and hepatic failures appeared, justifying a hemodialysis. Moreover, a deterioration of the coagulation function was observed, with major thrombocytopenia, thrombopathy and a decrease of coagulation factors. Fresh frozen plasmas and platelet transfusions were used during the following days to avoid hemorrhagic or thrombo-embolism risks. No specific therapies were instituted for the hepatic insufficiency, except to discharge the right ventricle by the venous canula, thus allowing the decrease of venous pressures in the right heart and in the splanchnic circulation.
Rapidly, this young patient presented five organ failures (cardiac, pulmonary, renal, hepatic and coagulation). However, due to a positive outcome of all dysfunctions under ECMO, after a step-by-step decrease of the fraction of inspired oxygen (10% per day) and of the flow rate of assistance (0.5 l per day), he could be weaned from pulmonary and cardiac extracorporeal supports, respectively, at postoperative days 9 and 14. Despite this positive evolution the outcome was not uneventful.
One week later, he presented a bilateral pneumonia followed, ten days later, by an acute ischemic cholecystitis with a biliary peritonitis surgically treated. A pacemaker was also implanted because of the persistence of the atrio-ventricular block. Seventy days after surgery, sedation and ventilation were discontinued, and the patient was discharged after 108 days. He resumed a professional activity as a computer supervisor without organ dysfunction one year later. The 3-year follow-up was uneventful and the echocardiographic control confirmed the stability of the repair.
3. Comment
The reported frequency of traumatic cardiac injuries after a road accident is lower than 0.1% but increases between 10 and 75% if a severe thoracic trauma is associated [1]. Mechanisms involved are: a direct cardiac trauma, a deceleration or a thoracic compression [2]. Several authors have reported urgent or delayed surgical repairs [3] and agree to perform an exhaustive trans-thoracic or trans-esophageal echocardiography to diagnose possible cardiac lesions and, therefore, to establish the surgical strategy.
In our case, the mechanism leading to this tricuspid valve disruption was probably an acute isovolumetric compression at the end of the cardiac diastole, when all cardiac valves are closed.
Various valvular lesions have been previously described with chordal or papillary muscle ruptures and leaflet tears [4]. Traumatic cardiac fistulae also have been reported, but are rare between aortic Valsalva's sinus and right heart cavities [5].
Bioprosthesis implantations in tricuspid position are related to a more important thrombosis risk compared to the other cardiac valves, essentially because of the low pressure in right cardiac cavities. Despite the moderate risk with biological substitutes, hemodynamic perturbations induced by the ECMO can significantly decrease the venous return, and as a consequence the cardiac flow rate in all cardiac cavities decreases as well [6]. In this case, a strict monitoring of the anticoagulation activity of the heparin is mandatory. Transesophageal or trans-thoracic echocardiographies must be performed regularly to ensure the recovery of the cardiac function and the absence of complications (thrombosis, valve dysfunction...).
Post-surgical indications of mechanical assistances remain debatable despite some published recommendations [7]. The presence of multiple organ failures is, for many authors, a real contraindication to implant this type of mechanical cardiac assistance [8]. However, our patient rapidly presented 5 organ failures, but the femoro-femoral ECMO was initially implanted mainly due to pulmonary and right cardiac insufficiencies. Several articles report an initial degradation of renal and hepatic functions [9] due to the traumatic myoglobin liberation and to blood flow rate variations in the hepato-splanchnic circulation after the implantation of a mechanical cardiac assistance.
The associated coagulation failure probably has several origins: the thrombocytopenia (45 Giga/l), the thrombopathy, and the coagulation factors decrease, were probably related to the cardiac repair itself, the pulmonary contusions and the biologic perturbation related to the ECMO implantation.
Finally, we believe that, severe traumatic cardiac and pulmonary failures in young patients, even associated in a second time with other visceral failures, are not a complete contraindication to a precocious ECMO implantation.
To conclude, we report this case to illustrate the risk of complex cardiac lesions after chest traumas, and to highlight the potential interest of the ECMO in the postoperative outcome of patients presenting multiple organ failure.
References
Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958; 18:371–396.
Olsovsky MR, Wechsler AS, Topaz O. Cardiac trauma. Diagnosis, management, and current therapy. Angiology 1997; 48:423–432.
Bertrand S, Laquay N, El Rassi I, Vouhe P. Tricuspid insufficiency after blunt chest trauma in a nine-year-old child. Eur J Cardiothorac Surg 1999; 16:587–589.
Maisano F, Lorusso R, Sandrelli L, Torracca L, Coletti G, La Canna G, Alfieri O. Valve repair for traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 1996; 10:867–873.
Kaya A, Dekkers P, Loforte A, Jaarsma W, Morshuis WJ. Traumatic aorto-right ventricular fistula with aortic insufficiency. Ann Thorac Surg 2005; 80:2362–2364.
Martin GR, Short BL. Doppler echocardiographic evaluation of cardiac performance in infants on prolonged extracorporeal membrane oxygenation. Am J Cardiol 1988; 62:929–934.
von Segesser LK. Cardiopulmonary support and extracorporeal membrane oxygenation for cardiac assist. Ann Thorac Surg 1999; 68:672–677.
Lewandowski K. Extracorporeal membrane oxygenation for severe acute respiratory failure. Crit Care 2000; 4:156–168.
Friedel N, Viazis P, Schiessler A, Warnecke H, Hennig E, Trittin A, Bottner W, Hetzer R. Recovery of end-organ failure during mechanical circulatory support. Eur J Cardiothorac Surg 1992; 6:519–522.(Sylvain Rubin, Pierre E. )
b Service de Chirurgie Thoracique et Cardiovasculaire, Hpital Jean-Minjoz, Boulevard Fleming, 25000 Besanon, France
Abstract
We report the case of a 30-year-old man admitted for a crushed chest trauma. The echocardiography found an aorto-right atrial fistula, a tricuspid valve rupture and a myocardial contusion. The fistula was closed using an autologous pericardial patch and a bioprosthetic tricuspid valve replacement was performed because the lesions did not allow for any valvular sparing. Because of the proximity between the right coronary ostium and the rupture, a venous aorto-right coronary bypass was performed. The ostium was also closed by the pericardial patch. A peripheral ECMO was implanted at the end of the surgical repair because of a right ventricle dysfunction and a respiratory failure related to severe bilateral pulmonary contusions. A few days later, renal, hepatic and coagulation failures were also noticed, justifying hemodialysis and transfusions. Despite an initial worsening of these five organ failures, the outcome was finally favorable and the patient was discharged 108 days after surgery. A 3-year follow-up revealed a complete recovery of all organ failures. To conclude, we firmly believe that the ECMO can be successfully applied in selected cases of severe right ventricular dysfunction and respiratory failure after cardiac surgery.
Key Words: Aortic root; Atrium; Trauma; Circulatory assistance temporary; Tricuspid valve; Rupture
1. Introduction
Chest traumas during road accidents are frequent and justify a detailed clinical examination. We report the case of a 30-year-old man, admitted for a chest crushing with severe cardiac and pulmonary lesions caused by a twelve-ton truck leading to a multiple organ failure treated by a post-operative ECMO implantation.
2. Clinical case
The thoracic examination found a transversal hematoma and multiple cardiac rubs. The chest X-ray revealed bilateral pulmonary contusions, rib fractures and a mediastinal enlargement. The echocardiography showed a rupture of the right aortic Valsalva's sinus into the right atrium and a large tricuspid insufficiency (Fig. 1). The ECG revealed a complete traumatic atrio-ventricular block.
A surgical repair was performed by sternotomy under extracorporeal circulation. The initial pericardial examination found no effusion or localized hematoma but a hypokinetic right ventricle. Using aortic and right atrial accesses, the Valsalva's sinus rupture was repaired with a pericardial patch fixed in glutaraldehyde, and a bioprosthetic tricuspid valve (Perimount from Carpentier–Edwards) was implanted because of the important valvular lesions. The right coronary ostium was closed and a venous aorto-right coronary bypass was performed, due to the proximity between the ostium and the rupture (Fig. 2).
At the end of the surgical repair, the right ventricle traumatic dysfunction worsened. As a result, the extracorporeal circulation weaning was impossible. The rapid implantation of a femoro-femoral extracorporeal membrane oxygenation (ECMO) support allowed for an increased cardiac flow close to 4.5 l/min. This ECMO, used at this time in our department, was built using a heparin bonded circuit of extracorporeal circulation from Medtronic with a Biomedicus pump and a classical fiber oxygenator.
The intravenous heparin therapy was continued for the full duration of the assistance allowing a partial thromboplastin time between 2.5 and 3 times the control value and the artificial ventilation was adapted using small insufflation volumes, low respiratory frequency and a moderate positive end-expiratory pressure of 5 cmH2O.
At post-operative day 2, renal and hepatic failures appeared, justifying a hemodialysis. Moreover, a deterioration of the coagulation function was observed, with major thrombocytopenia, thrombopathy and a decrease of coagulation factors. Fresh frozen plasmas and platelet transfusions were used during the following days to avoid hemorrhagic or thrombo-embolism risks. No specific therapies were instituted for the hepatic insufficiency, except to discharge the right ventricle by the venous canula, thus allowing the decrease of venous pressures in the right heart and in the splanchnic circulation.
Rapidly, this young patient presented five organ failures (cardiac, pulmonary, renal, hepatic and coagulation). However, due to a positive outcome of all dysfunctions under ECMO, after a step-by-step decrease of the fraction of inspired oxygen (10% per day) and of the flow rate of assistance (0.5 l per day), he could be weaned from pulmonary and cardiac extracorporeal supports, respectively, at postoperative days 9 and 14. Despite this positive evolution the outcome was not uneventful.
One week later, he presented a bilateral pneumonia followed, ten days later, by an acute ischemic cholecystitis with a biliary peritonitis surgically treated. A pacemaker was also implanted because of the persistence of the atrio-ventricular block. Seventy days after surgery, sedation and ventilation were discontinued, and the patient was discharged after 108 days. He resumed a professional activity as a computer supervisor without organ dysfunction one year later. The 3-year follow-up was uneventful and the echocardiographic control confirmed the stability of the repair.
3. Comment
The reported frequency of traumatic cardiac injuries after a road accident is lower than 0.1% but increases between 10 and 75% if a severe thoracic trauma is associated [1]. Mechanisms involved are: a direct cardiac trauma, a deceleration or a thoracic compression [2]. Several authors have reported urgent or delayed surgical repairs [3] and agree to perform an exhaustive trans-thoracic or trans-esophageal echocardiography to diagnose possible cardiac lesions and, therefore, to establish the surgical strategy.
In our case, the mechanism leading to this tricuspid valve disruption was probably an acute isovolumetric compression at the end of the cardiac diastole, when all cardiac valves are closed.
Various valvular lesions have been previously described with chordal or papillary muscle ruptures and leaflet tears [4]. Traumatic cardiac fistulae also have been reported, but are rare between aortic Valsalva's sinus and right heart cavities [5].
Bioprosthesis implantations in tricuspid position are related to a more important thrombosis risk compared to the other cardiac valves, essentially because of the low pressure in right cardiac cavities. Despite the moderate risk with biological substitutes, hemodynamic perturbations induced by the ECMO can significantly decrease the venous return, and as a consequence the cardiac flow rate in all cardiac cavities decreases as well [6]. In this case, a strict monitoring of the anticoagulation activity of the heparin is mandatory. Transesophageal or trans-thoracic echocardiographies must be performed regularly to ensure the recovery of the cardiac function and the absence of complications (thrombosis, valve dysfunction...).
Post-surgical indications of mechanical assistances remain debatable despite some published recommendations [7]. The presence of multiple organ failures is, for many authors, a real contraindication to implant this type of mechanical cardiac assistance [8]. However, our patient rapidly presented 5 organ failures, but the femoro-femoral ECMO was initially implanted mainly due to pulmonary and right cardiac insufficiencies. Several articles report an initial degradation of renal and hepatic functions [9] due to the traumatic myoglobin liberation and to blood flow rate variations in the hepato-splanchnic circulation after the implantation of a mechanical cardiac assistance.
The associated coagulation failure probably has several origins: the thrombocytopenia (45 Giga/l), the thrombopathy, and the coagulation factors decrease, were probably related to the cardiac repair itself, the pulmonary contusions and the biologic perturbation related to the ECMO implantation.
Finally, we believe that, severe traumatic cardiac and pulmonary failures in young patients, even associated in a second time with other visceral failures, are not a complete contraindication to a precocious ECMO implantation.
To conclude, we report this case to illustrate the risk of complex cardiac lesions after chest traumas, and to highlight the potential interest of the ECMO in the postoperative outcome of patients presenting multiple organ failure.
References
Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958; 18:371–396.
Olsovsky MR, Wechsler AS, Topaz O. Cardiac trauma. Diagnosis, management, and current therapy. Angiology 1997; 48:423–432.
Bertrand S, Laquay N, El Rassi I, Vouhe P. Tricuspid insufficiency after blunt chest trauma in a nine-year-old child. Eur J Cardiothorac Surg 1999; 16:587–589.
Maisano F, Lorusso R, Sandrelli L, Torracca L, Coletti G, La Canna G, Alfieri O. Valve repair for traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 1996; 10:867–873.
Kaya A, Dekkers P, Loforte A, Jaarsma W, Morshuis WJ. Traumatic aorto-right ventricular fistula with aortic insufficiency. Ann Thorac Surg 2005; 80:2362–2364.
Martin GR, Short BL. Doppler echocardiographic evaluation of cardiac performance in infants on prolonged extracorporeal membrane oxygenation. Am J Cardiol 1988; 62:929–934.
von Segesser LK. Cardiopulmonary support and extracorporeal membrane oxygenation for cardiac assist. Ann Thorac Surg 1999; 68:672–677.
Lewandowski K. Extracorporeal membrane oxygenation for severe acute respiratory failure. Crit Care 2000; 4:156–168.
Friedel N, Viazis P, Schiessler A, Warnecke H, Hennig E, Trittin A, Bottner W, Hetzer R. Recovery of end-organ failure during mechanical circulatory support. Eur J Cardiothorac Surg 1992; 6:519–522.(Sylvain Rubin, Pierre E. )