Although rare, various types of trauma can be responsible for valvular lesions that may not be recognized unless a systematic search is conducted after major penetrating or blunt trauma or following accidents. Traumatic valve injury can also be manifested as iatrogenic lesions resulting from surgery or interventional cardiology.
PATHOLOGY AND CLINICAL PRESENTATION
Penetrating cardiac trauma can affect the right ventricle, the left ventricle, and the great vessels. Laceration of the cardiac valves with acute valvular regurgitation attributable to leaflet tear or chordae or papillary muscle rupture may also occur.
Nonpenetrating or blunt trauma often occur secondary to falls or motor vehicle accidents with deceleration injuries. Valve injury can occur in the aortic, mitral, or tricuspid position. In the aortic position, the most common lesion is aortic leaflet tear or detachment from the annulus, particularly the non–coronary leaflet. In the mitral and tricuspid positions, leaflet tear or leaflet prolapse secondary to papillary muscle or chordae rupture can be observed.
In most instances, patients present with acute severe valvular regurgitation and hemodynamic deterioration requiring early diagnosis and surgical treatment. Occasionally following blunt trauma, valvular regurgitation can be well tolerated initially and the diagnosis may be delayed. For this reason, the work-up should be comprehensive in the setting of trauma. Associated cardiac lesions should be carefully investigated (such as myocardial contusion, hemopericardium, or ventricular septal rupture) as well as thoracic injuries (such as lung injury), aortic isthmus rupture, or extrathoracic injuries.
TRAUMATIC MITRAL REGURGITATION
Traumatic mitral valve regurgitation can result from chordae rupture, leaflet tear or disruption, and papillary muscle rupture. Reconstructive techniques are particularly indicated for traumatic mitral valve lesions in young patients because of the feasibility of valve reconstruction in the majority of cases. Excellent long-term results from reconstruction can be expected if the valvular tissue is otherwise normal. The techniques described in Section II can be used, guided by the functional approach and the “one lesion one technique” principle. Chordae rupture and/or leaflet tear are the most frequent mechanisms of regurgitation. They can be corrected by using the techniques described in Chapters 10 and 11 of Section II. In the case of papillary muscle rupture, papillary muscle reimplantation is a viable option in selected patients.
TRAUMATIC MITRAL REGURGITATION FOLLOWING PERCUTANEOUS MITRAL DILATATION
Percutaneous mitral dilatation is commonly used for the treatment of pure mitral stenosis without significant valvular calcification. The procedure can, however, be complicated by hemopericardium, left to right shunts, and the creation of a new mitral regurgitation.
Mitral valve regurgitation can be caused by several types of lesions. They include ( Table 33-1 ) leaflet tear, paracommissural tear ( Fig. 33-1 ), and papillary muscle or chordae rupture ( Fig. 33-2 ). A combination of several types of lesions is a common finding. Transthoracic echocardiography allows classification and localization of the dysfunction, and may also identify lesions such as papillary muscle rupture.
| Leaflet Tear | A2 | 4 |
| P2 | 2 | |
| Paracommissural Tear | Anterior | 4 |
| Posterior | 9 | |
| Chordae Rupture | 3 | |
| Papillary Muscle Rupture | 1 |
The immediate clinical presentation of this secondary mitral regurgitation is variable. Intractable pulmonary edema requiring emergent surgical correction may occur in some patients whereas in others the hemodynamic consequences are less dramatic and a conservative medical treatment can initially be established. Patients with moderate or severe mitral regurgitation should undergo valvular surgery soon after the percutaneous procedure since prolonged delay may compromise the likelihood of valve reconstruction. The feasibility of mitral valve reconstruction depends primarily on the extent of valvular lesions and the severity of calcifications. In our initial experience, valve reconstruction could be performed in more than 50% of the cases. A careful analysis of the lesion produced by the trauma must be conducted. It may be useful to resect the edge of the lesions and to take advantage of a tear to resect secondary chordae. Anterior leaflet tears should be closed with an autologous pericardial patch in order to preserve optimal leaflet surface area and mobility. Posterior leaflet tears can be reconstructed by direct suturing, or by leaflet resection and reconstruction with annular plication or leaflet extension. A paracommissural tear should be repaired with direct suture. Primary valve lesions are also addressed by the usual reconstructive techniques, such as standard commissurotomy, leaflet mobilization, prolapse correction, and remodeling annuloplasty. A septal inspection should also be performed to recognize a septal perforation commonly observed following percutaneous mitral dilation. Primary repair of this defect should be performed during the same procedure.
TRAUMATIC MITRAL REGURGITATION FOLLOWING PERCUTANEOUS MITRAL DILATATION
Percutaneous mitral dilatation is commonly used for the treatment of pure mitral stenosis without significant valvular calcification. The procedure can, however, be complicated by hemopericardium, left to right shunts, and the creation of a new mitral regurgitation.
Mitral valve regurgitation can be caused by several types of lesions. They include ( Table 33-1 ) leaflet tear, paracommissural tear ( Fig. 33-1 ), and papillary muscle or chordae rupture ( Fig. 33-2 ). A combination of several types of lesions is a common finding. Transthoracic echocardiography allows classification and localization of the dysfunction, and may also identify lesions such as papillary muscle rupture.
