SPC365

Hold your horses!

Session: Casos Clínicos: Insuficiência Cardíaca e Cuidados Intensivos Cardíacos
Speaker: Mónica Dias

Congress: CPC 2024
Topic: D. Heart Failure
Theme: 10. Chronic Heart Failure
Subtheme: 10.6 Chronic Heart Failure - Clinical
Session Type: Sessão de Casos Clínicos
FP Number: ---
Authors: Mónica Dias; Rodrigo Silva; Sofia Fernandes; Inês Conde; Carla Ferreira; Filipe Vilela; Carla Marques Pires; Alberto Salgado; Nuno Salomé; Nuno Antunes
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Gill Sans MT&quot;,sans-serif">Patient presentation: A 86-year-old man presented to the emergency department after being kicked in the chest by one of his horses, complaining of mechanical chest pain; he was previously asymptomatic. On initial assessment, he was hemodynamically stable, with mild hypoxemia, and a systolic murmur was heard at the left edge of the sternum. Previous ECG and transthoracic echocardiogram (TTE), carried out less than a year ago, had no significant alterations. &nbsp;</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Gill Sans MT&quot;,sans-serif">Initial workup: Initial ECG showed sinus rhythm with RBBB and blood tests elevation of troponin I (4.5 ng/mL). In this context, a cardiology assessment was requested due to a suspected cardiac contusion. TTE showed prolapse of one of the non-septal leaflets of tricuspid valve, with moderate to severe tricuspid regurgitation (TR); an image in the right ventricle (RV) suggestive of ruptured papillary muscle was observed. Chest CT excluded other relevant lesions. Transesophageal echocardiogram (TEE) confirmed the flail of the anterior leaflet of tricuspid valve with an image suggestive of a ruptured papillary muscle, leading to severe TR (figure 1). </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Gill Sans MT&quot;,sans-serif">Follow-up: The patient was hospitalized and remained stable. Considering the patient&rsquo;s age, the absence of symptoms, and normal right ventricular function, a conservative strategy was adopted.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Gill Sans MT&quot;,sans-serif">Conclusions: Traumatic tricuspid regurgitation is a rare complication of blunt thoracic trauma.<sup><span style="color:black">1,2 </span></sup>&nbsp;The force from a horse kick exceeds ten Kilonewtons and its impact to the body may induce many forms of cardiac injury. The tricuspid valve is the most affected valve because of the anterior location of the RV.<sup><span style="color:black">3</span></sup>&nbsp; </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Gill Sans MT&quot;,sans-serif">Frequently, at the early phase, patients with traumatic TR remain asymptomatic and the lesion may go undetected. In this patient, new right bundle branch block may have been the first sign of tricuspid injury. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Gill Sans MT&quot;,sans-serif">Surgical repair of the valve should be considered even before deterioration of the right ventricular function occurs to ensure better results.<sup><span style="color:black">4</span></sup> Nevertheless, considering the patient&#39;s advanced age, a more conservative strategy was adopted in this case. &nbsp;&nbsp;&nbsp;&nbsp; </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Gill Sans MT&quot;,sans-serif">In patients with blunt thoracic trauma, the possibility of cardiac injury, including TR, should be considered, and echocardiogram (TTE or TEE depending on the characteristics of the patient and the trauma) is the best initial method to exclude cardiac lesions.<sup><span style="color:black">5 </span></sup>New ECG abnormalities correlate with cardiac complications and may be the first sign of cardiac involvement in these cases.&nbsp; </span></span></span></span></p>