Traumatic rupture of the tricuspid valve and multi-modality imaging

Abstract

Introduction: Motor vehicle accident (MVA) account for most cases of traumatic rupture of the tricuspid valve. Valve rupture during an MVA is generated by an abrupt deceleration coupled with an increase in right-side cardiac pressures (Valsalva maneuver and thorax compression).

Case: A 39-year-old asymptomatic man was referred for an echocardiogram due to the presence of a systolic murmur. He had no prior significant medical history, except for a remote MVA 3 years ago. Real-time 3D echocardiography (RT3DE) showed a tear in the body of the anterior leaflet and not at the cord, as was suggested by two-dimensional transthoracic echocardiography (2D-TTE). Based on these findings, the mechanism was considered anterior leaflet rupture of the tricuspid valve, secondary to chest blunt trauma. The anterior leaflet was repaired using two polytetrafluoroethylene sutures, and tricuspid annuloplasty with an Edwards ring was performed.

Conclusions: Multimodality imaging helps to determine timing of surgery in asymptomatic traumatic tricuspid rupture. The combination of echocardiography and magnetic resonance imaging provide information of volumetric data and contractility of the right ventricle (RV) during follow-up. RT3DE gives information relevant to the morphological and functional characterization of the valve, allowing the planning of appropriate surgical procedure.

Keywords: Traumatic rupture of the tricuspid valve; cardiac magnetic resonance; three-dimensional transthoracic echocardiography.

Figure 1

TTE. (A) Left: longitudinal view of the RV during systole. Note the linear structure in the mid-portion of the tricuspid anterior leaflet (arrow) consistent with cord rupture. Nevertheless, it is interesting to note that central coaptation is not lost; (B) right side: color Doppler image showing severe TR; (C) left: post-processed full volume image. Tricuspid valve is viewed from the RV (diastole). Note a tear in the body of the anterior leaflet (arrow) and not at the chord, as was suggested by 2D-TTE. The tear is observed from the free border to the annulus; (D) right: post-processed full volume image. Tricuspid valve is viewed from the RV (systole) tricuspid valve is closed and folded. Note the persistence of a linear image indicative of an anterior leaflet rupture (arrow). Data acquisition was performed by two experienced sonographers using an ×3 matrix transducer connected to an RT-3DE system (IE33, Philips Medical Systems). Harmonic RT3DE imaging was performed in the same setting with the fully sampled matrix array transducer (×4, 2 to 4 MHz) that uses 3,000 elements to obtain a pyramidal volume data set from a single window. 2D-TTE, two-dimensional transthoracic echocardiography; RT3DE, real-time 3D echocardiography; RA, right atrium; RV, right ventricle; TR, tricuspid regurgitation.

Figure 2

TTE. Two-dimensional echocardiography. Four chamber view for see right ventricle (RV) (4). Available online: http://www.asvide.com/articles/310

Figure 3

TTE. Long view of right ventricle with color Doppler showing severe tricuspid regurgitation (TR). The regurgitation jet is directed towards posterior wall of the atrium (5). Available online: http://www.asvide.com/articles/311

Figure 4

TTE. Four chamber view with color Doppler showing severe TR. In this view it is not easy to identify which valve leaflet is involved to the regurgitation mechanisms (6). TR, tricuspid regurgitation. Available online: http://www.asvide.com/articles/312

Figure 5

TTE. Two-dimensional echocardiography. Long view of right ventricle. A linear image is observed on the atrial surface of the anterior leaflet (7). Available online: http://www.asvide.com/articles/313

Figure 6

TTE RT3DE. Post-processed full volume image. Tricuspid valve is viewed from the RA. Tricuspid valve is closed and folded. Note the persistence of a linear image indicative of an anterior leaflet rupture (8). RT3DE, real-time 3D echocardiography; RA, right atrium. Available online: http://www.asvide.com/articles/314

Figure 7

TTE RT3DE. Post-processed full volume image. Tricuspid valve is viewed from the RV. Note a tear in the body of the anterior leaflet. The tear is observed from the free border to the annulus (9). RT3DE, real-time 3D echocardiography; RV, right ventricle. Available online: http://www.asvide.com/articles/315

Figure 8

(A) Cardiac magnetic resonance: balanced steady-state free precession sequence (CINE). Four-chamber views during diastole showing the RV diameters at different levels. The volumes of the RV were 237 mL volume of end diastole and 130 mL for volume of end systole. The ejection fraction calculated for the RV was 45%; (B) tissue Doppler image. RV function by tissue Doppler imaging was normal (tricuspid annular systolic velocity >12 cm/s); (C) two-dimensional image of the inferior vena cava with normal inspiratory collapse suggest normal right-side cardiac and venous pressures despite volume overload. LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium; TDI, tissue Doppler image; IVC, inferior vena cava.