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A Rare Cause of Chronic Mitral Regurgitation: Perivalvular Ventriculoatrial Fistulous Communication from Remote Blunt Chest Trauma
A Rare Cause of Chronic Mitral Regurgitation: Perivalvular Ventriculoatrial Fistulous Communication from Remote Blunt Chest Trauma Mohammad Sahebjam, MD, Mehrab Marzban, MD, Abbas Soleimani, MD, and Arezou Zoroufian, MD, Tehran, Iran
We report a rare case of a 31-year-old man with chronic severe mitral regurgitation as a result of perivalvular ventriculoatrial fistulous communication with a history of remote blunt chest trauma at age 19 to 20 years who underwent successful surgical repair. Mitral regurgitation after blunt trauma is usually secondary to rupture of the chordae tendi-
CASE REPORT A 31-year-old man with about a 2-year history of exertional dyspnea was referred to our hospital for assessment of mitral valve regurgitation severity and mechanism. He had a history of blunt chest trauma during a motor vehicle accident at age 19 to 20 years. Subsequently he had no symptoms and had good functional capacity but during routine physical examination, his doctor noticed a heart murmur and the patient was referred to a cardiologist for evaluation of cardiac murmur. Thereafter he was under observation and treatment with suggestion of rheumatic mitral valve regurgitation. Physical examination on presentation to our hospital demonstrated high-grade pansystolic murmur and atrial fibrillation rhythm. Transthoracic echocardiography (Figure 1; Videos 1 and 2) and transesophageal echocardiography (Figures 2 and 3; Videos 3 and 4) demonstrated structurally normal mitral valve leaflets and chordae tendinae with mild central transvalvular regurgitation but there was severe eccentric mitral regurgitation away from the line of coaptation that its flow was through the annulus. The perivalvular leak was going around the posteroinferior portion of the mitral annulus. The fistulous communication around the valve measured 11 to 12 mm opening on left ventricFrom the Departments of Echocardiography, Cardiac Surgery (M.M.), and Interventional Cardiology (A.S.), Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. Reprint requests: Mohammad Sahebjam, MD, Department of Echocardiography, Tehran Heart Center, Jalal Al Ahmad and North Kargar Cross, 1411713138 Tehran, Iran (E-mail: [email protected]). 0894-7317/$32.00 Copyright 2007 by the American Society of Echocardiography. doi:10.1016/j.echo.2007.04.016
nae or papillary muscles and perivalvular regurgitation is a very rare event especially after remote blunt chest trauma. We present a case with severe mitral regurgitation secondary to remote blunt chest trauma as a result of perivalvular ventriculoatrial fistulous communication. (J Am Soc Echocardiogr 2007;20:1416.e3-1416.e5.)
ular (LV) side and about 6 to 8 mm on left atrial side. The posteronferior portion of mitral valve annulus was thickened and there was bulging of basal ventricular wall adjacent to this site. The aortic valve was normal. The left atrium and LV were severely dilated. The LV systolic ejection fraction was estimated to be about 35%. There was also moderate tricuspid valve regurgitation with estimated right ventricular systolic pressure of 55 mm Hg. Cardiac catheterization and coronary angiography demonstrated normal coronary arteries with bulging of basal inferior of LV and severe eccentric mitral regurgitation. The patient was referred for surgical repair of mitral regurgitation. The findings on surgical field were the same as echocardiography and the perivalvular mitral regurgitation was successfully repaired. Postoperative transthoracic echocardiography (Figures 4 and 5; Video 5) showed no perivalvular regurgitation and there was only minimal transvalvular mitral regurgitation. Postoperatively, the patient had pericardial effusion that was surgically drained and, currently, the patient has better exercise tolerance and less dyspnea on exertion.
DISCUSSION The incidence of traumatic heart injury caused by motor vehicle accidents has been increasing in civilian life; however, blunt chest trauma is uncommonly followed by cardiac valvular injuries.1,2 The mitral valve apparatus injury caused by blunt chest trauma is rare and may be overlooked for months to years from the accident.1,3-5 There are case reports with intervals between index blunt chest trauma and surgical repair of more than 20 years.4,5 The most common mitral lesion is rupture
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Figure 1 Transthoracic echocardiogram showing perivalvular fistulous communication (arrows and asterisks) between left atrium (LA) and left ventricle (LV).
Figure 3 Transesophageal echocardiogram showing severe perivalvular eccentric mitral regurgitation. LA, Left atrium; LV, left ventricle.
Figure 2 Transesophageal echocardiogram showing perivalvular fistulous communication (arrows and asterisks) between left atrium (LA) and left ventricle (LV).
Figure 4 Postoperative echocardiogram showing mild transvalvular regurgitation without perivalvular regurgitation. LA, Left atrium; LV, left ventricle; PE, pericardial effusion.
of the papillary muscles, followed by the chordae tendineae and leaflet tear.6 Echocardiography, especially transesophageal echocardiography, is the test of choice to diagnose these conditions.7 Chronic mitral regurgitation secondary to perivalvular leak of native valve is a very event and we could find only one other case report, by Devarapalli and Segar,5 that the mechanism of chronic mitral regurgitation was perivalvular leakage and left ventriculoatrial fistulous communication from remote blunt chest trauma that was repaired successfully. The case of Devarapalli and Segar5 was a 49-yearold man with history of blunt chest trauma at age 18 years who presented with 1-year history of progressive dyspnea, fatigue, and decreased functional capacity (about 30 years after index chest trauma). Perivalvular leakage of prosthetic mitral
valve secondary to blunt chest trauma has also been reported.8 There are two presumed mechanisms for developing this abnormality during blunt chest trauma. The first possible mechanism is annular dehiscence as a result of a sudden dramatic increase in intracardiac pressure against a closed mitral valve resulting in tearing of a portion of the annulus from the adjoining wall.9 The second possible mechanism is blunt cardiac injury (formerly known as cardiac contusion) that occurred during blunt chest trauma and developed to dehiscence in mitral perivalvular tissue with resulting fistulous communication. The recent large multistate study by Ismailov et al10 showed that blunt cardiac injury was significantly associated with mitral valve insufficieny, incompe-
Journal of the American Society of Echocardiography Volume 20 Number 12
Sahebjam et al 1416.e5
mitral regurgitation with different mechanisms, so a high index of suspicion coupled with appropriate diagnostic tests, especially echocardiography, are necessary for accurate diagnosis and successful operative correction. REFERENCES
Figure 5 Arrow showing surgically closed side of fistula. LA, Left atrium; LV, left ventricle.
tence, and regurgitation in univariate analysis (P ⬍ .001). As for the delayed symptoms presentation, we thought that with the passage of time and incremental tension on perivalvular tissue because of left ventriculoatrial enlargement secondary to volume overload, the fistulous communication that was probably small at the beginning of the event gradually enlarged and severity of regurgitation increased. Thereafter, the patient became symptomatic with development of LV failure, like the pattern of presentation of symptoms in chronic mitral regurgitation secondary to other mechanisms. Conclusion Mitral valve injury secondary to nonpenetrating cardiac trauma is uncommon but can cause significant
1. Kumagai H, Hamanaka Y, Hirai S, Mitsui N, Kobayashi T. Mitral valve plasty for mitral regurgitation after blunt chest trauma. Ann Thorac Cardiovasc Surg 2001;7:175-9. 2. Kan CD, Yang YJ. Traumatic aortic and mitral valve injury following chest injury with a variable clinical course. Heart 2005;91:568-70. 3. Guhathakurta S, Chen Q, Nalladaru Z, Squire BH, Sharma AK. Delayed traumatic mitral regurgitation after blunt chest trauma. J Trauma Injury Infect Crit Care 1999;47:982-4. 4. Bailey CP, Vera C, Hirose T. Mitral regurgitation from rupture of chordae tendineae due to “steering wheel” compression. Geriatrics 1969;24:90-105. 5. Devarapalli S, Segar DS. Chronic mitral regurgitation secondary to a perivalvular leak from remote trauma. J Am Soc Echocardiogr 2003;16:1082-4. 6. Reardon MJ, Conklin LD, Letsou GV, Safi HJ, Espada R, Baldwin JC. Mitral valve injury from blunt trauma. J Heart Valve Dis 1998;7:467-70. 7. Zakynthinos EG, Vassilakopoulos T, Routsi C, Roussos C, Zakynthinos S. Early- and late-onset atrioventricular valve rupture after blunt chest trauma: the usefulness of transesophageal echocardiography. J Trauma 2002;52:990-6. 8. Brady PW, Deal CW. An unusual cause of mitral incompetence: post-traumatic paraprosthetic mitral incompetence. J Trauma 1988;28:259-61. 9. Feigenbaum H, Armestrong WF, Ryan T. Feigenbaum’s echocardiography. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 349. 10. Ismailov RM, Weiss HB, Ness RB, Lawrence BA, Miller TR. Blunt cardiac injury associated with cardiac valve insufficiency: trauma links to chronic disease? Injury 2005;36:1022-8.
We report a rare case of a 31-year-old man with chronic severe mitral regurgitation as a result of perivalvular ventriculoatrial fistulous communication with a history of remote blunt chest trauma at age 19 to 20 years who underwent successful surgical repair. Mitral regurgitation after blunt trauma is usually secondary to rupture of the chordae tendi-
CASE REPORT A 31-year-old man with about a 2-year history of exertional dyspnea was referred to our hospital for assessment of mitral valve regurgitation severity and mechanism. He had a history of blunt chest trauma during a motor vehicle accident at age 19 to 20 years. Subsequently he had no symptoms and had good functional capacity but during routine physical examination, his doctor noticed a heart murmur and the patient was referred to a cardiologist for evaluation of cardiac murmur. Thereafter he was under observation and treatment with suggestion of rheumatic mitral valve regurgitation. Physical examination on presentation to our hospital demonstrated high-grade pansystolic murmur and atrial fibrillation rhythm. Transthoracic echocardiography (Figure 1; Videos 1 and 2) and transesophageal echocardiography (Figures 2 and 3; Videos 3 and 4) demonstrated structurally normal mitral valve leaflets and chordae tendinae with mild central transvalvular regurgitation but there was severe eccentric mitral regurgitation away from the line of coaptation that its flow was through the annulus. The perivalvular leak was going around the posteroinferior portion of the mitral annulus. The fistulous communication around the valve measured 11 to 12 mm opening on left ventricFrom the Departments of Echocardiography, Cardiac Surgery (M.M.), and Interventional Cardiology (A.S.), Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. Reprint requests: Mohammad Sahebjam, MD, Department of Echocardiography, Tehran Heart Center, Jalal Al Ahmad and North Kargar Cross, 1411713138 Tehran, Iran (E-mail: [email protected]). 0894-7317/$32.00 Copyright 2007 by the American Society of Echocardiography. doi:10.1016/j.echo.2007.04.016
nae or papillary muscles and perivalvular regurgitation is a very rare event especially after remote blunt chest trauma. We present a case with severe mitral regurgitation secondary to remote blunt chest trauma as a result of perivalvular ventriculoatrial fistulous communication. (J Am Soc Echocardiogr 2007;20:1416.e3-1416.e5.)
ular (LV) side and about 6 to 8 mm on left atrial side. The posteronferior portion of mitral valve annulus was thickened and there was bulging of basal ventricular wall adjacent to this site. The aortic valve was normal. The left atrium and LV were severely dilated. The LV systolic ejection fraction was estimated to be about 35%. There was also moderate tricuspid valve regurgitation with estimated right ventricular systolic pressure of 55 mm Hg. Cardiac catheterization and coronary angiography demonstrated normal coronary arteries with bulging of basal inferior of LV and severe eccentric mitral regurgitation. The patient was referred for surgical repair of mitral regurgitation. The findings on surgical field were the same as echocardiography and the perivalvular mitral regurgitation was successfully repaired. Postoperative transthoracic echocardiography (Figures 4 and 5; Video 5) showed no perivalvular regurgitation and there was only minimal transvalvular mitral regurgitation. Postoperatively, the patient had pericardial effusion that was surgically drained and, currently, the patient has better exercise tolerance and less dyspnea on exertion.
DISCUSSION The incidence of traumatic heart injury caused by motor vehicle accidents has been increasing in civilian life; however, blunt chest trauma is uncommonly followed by cardiac valvular injuries.1,2 The mitral valve apparatus injury caused by blunt chest trauma is rare and may be overlooked for months to years from the accident.1,3-5 There are case reports with intervals between index blunt chest trauma and surgical repair of more than 20 years.4,5 The most common mitral lesion is rupture
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1416.e4 Sahebjam et al
Journal of the American Society of Echocardiography December 2007
Figure 1 Transthoracic echocardiogram showing perivalvular fistulous communication (arrows and asterisks) between left atrium (LA) and left ventricle (LV).
Figure 3 Transesophageal echocardiogram showing severe perivalvular eccentric mitral regurgitation. LA, Left atrium; LV, left ventricle.
Figure 2 Transesophageal echocardiogram showing perivalvular fistulous communication (arrows and asterisks) between left atrium (LA) and left ventricle (LV).
Figure 4 Postoperative echocardiogram showing mild transvalvular regurgitation without perivalvular regurgitation. LA, Left atrium; LV, left ventricle; PE, pericardial effusion.
of the papillary muscles, followed by the chordae tendineae and leaflet tear.6 Echocardiography, especially transesophageal echocardiography, is the test of choice to diagnose these conditions.7 Chronic mitral regurgitation secondary to perivalvular leak of native valve is a very event and we could find only one other case report, by Devarapalli and Segar,5 that the mechanism of chronic mitral regurgitation was perivalvular leakage and left ventriculoatrial fistulous communication from remote blunt chest trauma that was repaired successfully. The case of Devarapalli and Segar5 was a 49-yearold man with history of blunt chest trauma at age 18 years who presented with 1-year history of progressive dyspnea, fatigue, and decreased functional capacity (about 30 years after index chest trauma). Perivalvular leakage of prosthetic mitral
valve secondary to blunt chest trauma has also been reported.8 There are two presumed mechanisms for developing this abnormality during blunt chest trauma. The first possible mechanism is annular dehiscence as a result of a sudden dramatic increase in intracardiac pressure against a closed mitral valve resulting in tearing of a portion of the annulus from the adjoining wall.9 The second possible mechanism is blunt cardiac injury (formerly known as cardiac contusion) that occurred during blunt chest trauma and developed to dehiscence in mitral perivalvular tissue with resulting fistulous communication. The recent large multistate study by Ismailov et al10 showed that blunt cardiac injury was significantly associated with mitral valve insufficieny, incompe-
Journal of the American Society of Echocardiography Volume 20 Number 12
Sahebjam et al 1416.e5
mitral regurgitation with different mechanisms, so a high index of suspicion coupled with appropriate diagnostic tests, especially echocardiography, are necessary for accurate diagnosis and successful operative correction. REFERENCES
Figure 5 Arrow showing surgically closed side of fistula. LA, Left atrium; LV, left ventricle.
tence, and regurgitation in univariate analysis (P ⬍ .001). As for the delayed symptoms presentation, we thought that with the passage of time and incremental tension on perivalvular tissue because of left ventriculoatrial enlargement secondary to volume overload, the fistulous communication that was probably small at the beginning of the event gradually enlarged and severity of regurgitation increased. Thereafter, the patient became symptomatic with development of LV failure, like the pattern of presentation of symptoms in chronic mitral regurgitation secondary to other mechanisms. Conclusion Mitral valve injury secondary to nonpenetrating cardiac trauma is uncommon but can cause significant
1. Kumagai H, Hamanaka Y, Hirai S, Mitsui N, Kobayashi T. Mitral valve plasty for mitral regurgitation after blunt chest trauma. Ann Thorac Cardiovasc Surg 2001;7:175-9. 2. Kan CD, Yang YJ. Traumatic aortic and mitral valve injury following chest injury with a variable clinical course. Heart 2005;91:568-70. 3. Guhathakurta S, Chen Q, Nalladaru Z, Squire BH, Sharma AK. Delayed traumatic mitral regurgitation after blunt chest trauma. J Trauma Injury Infect Crit Care 1999;47:982-4. 4. Bailey CP, Vera C, Hirose T. Mitral regurgitation from rupture of chordae tendineae due to “steering wheel” compression. Geriatrics 1969;24:90-105. 5. Devarapalli S, Segar DS. Chronic mitral regurgitation secondary to a perivalvular leak from remote trauma. J Am Soc Echocardiogr 2003;16:1082-4. 6. Reardon MJ, Conklin LD, Letsou GV, Safi HJ, Espada R, Baldwin JC. Mitral valve injury from blunt trauma. J Heart Valve Dis 1998;7:467-70. 7. Zakynthinos EG, Vassilakopoulos T, Routsi C, Roussos C, Zakynthinos S. Early- and late-onset atrioventricular valve rupture after blunt chest trauma: the usefulness of transesophageal echocardiography. J Trauma 2002;52:990-6. 8. Brady PW, Deal CW. An unusual cause of mitral incompetence: post-traumatic paraprosthetic mitral incompetence. J Trauma 1988;28:259-61. 9. Feigenbaum H, Armestrong WF, Ryan T. Feigenbaum’s echocardiography. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 349. 10. Ismailov RM, Weiss HB, Ness RB, Lawrence BA, Miller TR. Blunt cardiac injury associated with cardiac valve insufficiency: trauma links to chronic disease? Injury 2005;36:1022-8.