Medical Student Kansas City University Denver, Colorado, United States
Introduction: Refractory hypotension and sinus tachycardia in a patient with severe chest trauma should raise suspicion for blunt cardiac injury. Among those with cardiac injury, aortic valve rupture is rare and carries high mortality. This is a case report of acute cardiogenic shock due to aortic valve cusp rupture from blunt chest trauma.
Description: A 67-year-old male skier attempted a backflip off a 60-foot jump. The patient suffered bilateral rib, pelvic, femur, and unstable spine fractures. On arrival to our level one trauma center the patient became profoundly tachycardic and hypotensive. Physical examination revealed a diastolic murmur, trauma imaging was negative for internal hemorrhage, and the initial high-sensitivity troponin was elevated. EKG was normal, and transthoracic echocardiography revealed acute severe aortic insufficiency with valve rupture. Cardiac surgery was consulted. Due to hemodynamic instability, worsening respiratory status, and risk of epidural hematoma due to unstable spinal fractures, the consensus was to proceed with transcatheter aortic valve replacement. Intra-operative transesophageal echo revealed rupture of both the non-coronary and right coronary cusps of the aortic valve. Valve deployment was complicated by hemodynamic collapse with ventricular fibrillation. Immediate aortic root angiogram demonstrated occlusion of the left main coronary artery. The patient was emergently placed onto cardiopulmonary bypass and a sternotomy was performed. A torn cusp of the non-coronary leaflet was found to have occluded the left main coronary artery, resulting in arrest. The valve was successfully replaced, mechanical left ventricular support was temporarily required, and he later underwent spine and femur fixation. Left ventricular function recovered and the patient was discharged neurologically intact to a rehabilitation facility 46 days later.
Discussion: Blunt cardiac injury resulting in aortic valve rupture with acute cardiogenic shock is rare. To our knowledge, there is no published evidence of survival following traumatic rupture of two aortic valve cusps and discharge from the hospital neurologically intact with normal cardiac function. High index of suspicion, accurate diagnosis, and urgent operative intervention are imperative for improving survival rates.
