Abstract
Blunt chest trauma has seldom been reported as a cause of rupture of an aortic valve cusp. We report the case of a 63-year-old man who had a motor vehicle collision resulting in transection of the descending thoracic aorta, splenic pseudoaneurysm, and rupture of an aortic valve cusp causing severe aortic regurgitation. Despite replacement of the aortic valve, he died of multiorgan failure.
CASE DESCRIPTION
A 63-year-old hypertensive man was brought to the emergency room after a motor vehicle collision in which he was the restrained driver of a vehicle struck on the passenger side. On arrival his heart rate was 120 beats per minute and his systolic blood pressure was 90 mm Hg. Precordial auscultation disclosed no murmurs. Computed tomography of the chest with contrast showed transection of the descending thoracic aorta and splenic aneurysms. He underwent endovascular repair of the thoracic aorta; due to persistent hypotension, he also underwent exploratory laparotomy, which had unremarkable findings. On return to the intensive care unit, his blood pressure was 100/30 mm Hg. Transthoracic echocardiogram revealed holodiastolic flow reversal in the aorta and a short pressure half time of 146 milliseconds (Figure 1). Transesophageal echocardiography excluded aortic dissection and further demonstrated perforation of the left and noncoronary cusps (Figure 2). Emergent aortic valve replacement with a 25 mm Medtronic porcine bioprosthesis was performed, but the patient died 48 hours following the operation.
Figure 1.
(a) Continuous wave Doppler of the aortic valve and (b) pulsed wave Doppler of the descending thoracic aorta. The measured pressure half time is 146 milliseconds with a dense Doppler signal, and there is holodiastolic flow reversal. These findings are concerning for severe aortic regurgitation.
Figure 2.
Transesophageal echocardiography with long-axis view of the aortic valve. Perforation of the noncoronary cusp can be appreciated with diastolic flow traveling through it, as demonstrated with color Doppler.
DISCUSSION
Traumatic aortic regurgitation is rare (1), with less than 100 cases dating to 2002 (2). It is believed that if blunt force chest trauma occurs during ventricular diastole, the rise of intraaortic pressure against a closed aortic valve may cause rupture or detachment of one or more cusps. The noncoronary cusp is the most commonly affected (3). The acute regurgitant flow causes a marked increase in left ventricular end diastolic pressure, which reduces the coronary perfusion gradient, resulting in diffuse myocardial ischemia. Typically, cardiogenic shock and death follow without emergent intervention (4).
References
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