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Blunt Traumatic Injury to the Aortic Root and Aortic Valve.

February 1, 2018 • Volume 10 • Number 3 cases-anesthesia-analgesia.org 65 DOI: 10.1213/XAA.0000000000000701 A 51-year-old man with a history of polysubstance abuse and no other known medical history presented to our trauma center after attempted suicide with a fifty-foot fall from a bridge into water. He sustained multiple orthopedic injuries including: a left sixth rib fracture, left femur fracture, left olecranon fracture, left L1–L3 transverse process fractures, and left acetabular fracture. Computed tomography (CT) scan of the chest with contrast at admission did not show evidence of aortic dissection or rupture. His olecranon, femur, and acetabular fractures were treated surgically within the first 48 hours of hospitalization. On hospital day 2, he underwent a transthoracic echocardiogram (TTE) to evaluate ventricular function. Transthoracic echocardiogram demonstrated severe aortic insufficiency (AI), but no other abnormalities. On hospital day 8, he was scheduled for aortic valve replacement surgery. Intraoperative transesophageal echocardiography (TEE) demonstrated severe AI in the midesophageal (ME) aortic valve longand short-axis views (Figure 1; Supplemental Digital Content 1, Video 1, http:// links.lww.com/AA/B893). A small pericardial effusion was also present. No vegetation was visualized on the aortic valve and the left ventricle was normal size. The etiology for the patient’s AI was prolapse of the noncoronary cusp (NCC) with a jet directed away from the prolapsing cusp (Figure 1; Supplemental Digital Content 1, Video 1, http:// links.lww.com/AA/B893). The prolapsing cusp was identified as the NCC by turning the probe shaft clockwise in the ME aortic valve long-axis view, which typically brings the NCC into view compared to the left coronary cusp (LCC), which is brought into view by turning the probe shaft counterclockwise. Two-dimensional (2D) echocardiography in the ME aortic valve short-axis view further demonstrated an outpouching in the aortic root just above the aortic valve annulus (Figure 2A). Three-dimensional (3D) echocardiography confirmed this defect, which was directly above the origin of the right coronary cusp (RCC) and NCC commissure (Figure 2B; Supplemental Digital Content 2, Video 2, http://links.lww.com/AA/B894). 3D imaging confirmed no vegetation was present. Comprehensive TEE examination did not show other abnormalities. The patient was cannulated centrally for cardiopulmonary bypass and had standard aortic cross clamping. Surgical inspection of the valve and aortic root demonstrated traumatic contained rupture (pseudoaneurysm) of the aorta just above the RCC and NCC commissure. The rupture was contained by aortic adventitia, which prevented cardiac tamponade. Primary surgical repair of the aortic tear was performed in conjunction with aortic valve replacement and the patient had an excellent outcome.