Discussion
We presented the case of a car driver who sustained chest-wall trauma
and then developed severe TR due to tricuspid valve leaflet perforation
and annulus dilatation after blunt trauma. The mechanism of tricuspid
valve injury is still controversial. Anatomically, the right ventricle
is likely to have vulnerability to blunt trauma due to increased
hydrostatic pressure by anteroposterior compression from the adjacent
sternum7. When a deceleration force especially during
the end-diastolic phase is transmitted through the ventricle, a forceful
regurgitant blood flow can cause the rupture of a papillary muscle or of
the chordae tendineae8. Delayed valvular rupture or
avulsion may occur due to papillary muscle contusion with hemorrhage,
inflammation, and late necrosis, leading to disruption over
time6. If the damage is severe, symptomatic clinical
deterioration and hemodynamic compromise can
result. Blunt chest-wall trauma
during high-speed motor vehicle accidents is common; however, valvular
rupture or perforation is rare (less than 1%) and may present
late9,10 which is similar to our case worsening
progressively and causing severe TR later.
In our case, TR had been monitored and managed appropriately ,however,
etiology of TR was not clear. The etiology of TR may be missed by
2-Dimentional(2-D) imaging and 3-Dimentional (3-D) TEE may provide
definitive anatomic evaluation of the tricuspid apparatus for treatment
planning11. As
was seen in our patient, damage to tricuspid valve leaflet was missed on
2-D imaging which only showed annual dilatation and severe TR.
Intraoperative 3-D echocardiographic imaging was able to show detailed
anatomical and functional evaluation of the tricuspid apparatus.
Generally, tricuspid valve repair is preferable to valve
replacement9,11. Whether to perform early surgery in
patients who have sustained severe traumatic TR is still controversial.
Traumatic TR is amenable to reparative techniques; however, delayed
presentation impairs the success of surgical repair12.
Particularly in patients who present late, surgical findings include
contracted and atrophic papillary muscles, chordae, and valve
leaflets5. Performing surgery before right ventricular
dysfunction occurs will enhance the possibility of an adequate result
and the subsequent maintenance of sinus rhythm12. In
this case, complex anatomical valve dysfunction confirmed by
intraoperative TEE allowed a decision for valve replacement.