Blunt Thoracic Trauma-Induced Mitral Papillary Muscle Avulsion with Pericardial Rupture and Cardiac Herniation: Difficult and Delayed Diagnoses

Abstract

Blunt thoracic trauma (BTT) and the resultant isolated mitral papillary muscle avulsion, pericardial rupture, and cardiac herniation injuries are each rarely diagnosed clinical entities. We describe the first case of combined pericardial tear with cardiac herniation and ruptured mitral papillary muscles following BTT. Preoperative transesophageal echocardiography (TEE) diagnosed the delayed mitral papillary muscle rupture while all previous diagnostic modalities failed to delineate the pericardial rupture and cardiac herniation. Particular emphasis is placed on the clinical and radiologic aspects of the case that would heighten clinical suspicion in the emergency setting where blunt cardiac injury sequelae are suspected and frequently missed.

Incidental Finding of Traumatic Papillary Muscle Rupture on Intraoperative Transesophageal Echocardiogram following a Motor Vehicle Accident

“…Although acute MR following blunt chest trauma can be seen after motor vehicle accidents, the overall prevalence of acute MR following blunt chest trauma is low. 3 , 4 , 5 One often cited study demonstrated that of 546 cases of cardiac injury from trauma, damage to the mitral valve was seen in just 0.01%. 6 Cardiac contusion is more commonly seen following this mechanism of injury.…”

Is There a Role for Transesophageal Echocardiography in the Perioperative Trauma Patient?

“…In addition to the diagnosis of BTAI, TEE in blunt trauma is relevant for the diagnosis of other cardiac injuries, such as cardiac rupture [ 18 ], papillary muscle avulsion [ 19 ], aortic valve rupture [ 20 , 21 ], and cardiac contusions [ 22 ]. Similarly, Artnfield et al presented a case where bedside TEE was performed by an emergency physician in a trauma patient with evidence of shock of unclear etiology where the TEE demonstrated a significant BTAI with a significant hematoma causing cardiac tamponade physiology [ 23 ].…”

Current status of point of care ultrasonography for the perioperative care of trauma patients

“…The use of TEE has demonstrated to have high sensitivity and specificity for the diagnosis of aortic injuries [20,21]. Other traumatic cardiac injuries that are easy to identify with TEE include cardiac tears [22], aortic valve avulsion [23] and papillary muscle avulsions [24].…”