Chapter 13 / Operative Management 199
Table 1
Representative Traumatic Tricuspid Valve Injury Reported in the Literature
Trauma Operative Valve Operative
Author (ref.) Age (yr) mechanism interval pathology strategy
Halstead et al. (30) 19 MVA Initial Papillary rupture Repair
Doty et al. (31) 27 Gunshot 4 yr Leaflet perforation Repair
Morelli et al. (32) 25 Stab wound 1 yr N.A. None
Trotter et al. (33) 15 MVA Initial Annulus rupture Bioprosthesis
Pearson et al. (34) 5Crush injury 2 mo Annulus rupture N.A.
Pearson et al. (34) 7 Pedestrian 7 yr Chordal rupture N.A.
Banning et al. (35) 19 MVA Initial Chordal rupture Bioprosthesis
Stahl et al. (36) 30 MVA Initial Papillary rupture Bioprosthesis
Chirillo et al. (37) N.A. Blunt chest N.A. N.A. N.A.
Bolton et al. (38) 37 Stab wound 17 yr Leaflet disruption Repair
Abbreviations: MVA = motor vehicle accident; N.A. = not available.
Note: There are well over 100 cases of traumatic tricuspid valve injury cited in the literature since the
first credited report by Williams in 1829.
blunt chest trauma, DeMuth et al. noted ventricular septal lacerations in 33% of
canines, and 60% ventricular septums sustained contusions (24) despite a grossly unin-
jured appearance to the epicardium. In an autopsy series from the Armed Forces Insti-
tute of Pathology, traumatic atrial septal defects were noted in 4.5% of cases and
traumatic ventricular septal defects were noted in 5.5% (25). Only 20% of these defects
were isolated injuries, most commonly associated with valvular injury. Awareness of
this prevalence is important when evaluating patients with blunt cardiac injury, as the
prevailing valvular dysfunction may divert attention from the associated septal defect.
Operative intervention for traumatic septal defects requires cardiopulmonary
bypass, and a midline sternotomy is preferred. Intraoperative transesophageal echocar-
diography is used routinely in our practice. Closure of traumatic ventricular septal
defects have been described with both a direct suture approximation (26) and use of a
patch (27,28). The choice of cardiac incisions, use of prosthetic material versus autolo-
gous pericardium, and timing of intervention will depend on the concomitant proce-
dures performed, as well as surgeon preferences. As the majority of reported traumatic
ventricular septal defects occur within the apical muscular septum, residual defects
may remain; the literature contains at least one report of spontaneous closure of a small
residual shunt (29).
ATRIOVENTRICULAR VALVE INJURY
The mechanism of atrioventricular valve injury is thought to be a sudden compres-
sive force to the heart at the end of diastole, when the heart is full and the atrioventric-
ular valves are closed. Diagnosis of atrioventricular valve abnormalities can be
confirmed by transthoracic or transesophageal echocardiography.
Tricuspid Valve Injury: Tricuspid valve injury is predominantly confined to motor
vehicle accidents in the developed countries, although deceleration falls and crush
injuries have been reported (Table 1). Because of the anterior location of the right ven-
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