Traumatic aorto-right atrial fistula and tricuspid valve rupture. Post-operative cardiac and respiratory support with extracorporeal membrane oxygenation

Abstract

We report the case of a 30-year-old man admitted for a crushed chest trauma. The echocardiography found an aorto-right atrial fistula, a tricuspid valve rupture and a myocardial contusion. The fistula was closed using an autologous pericardial patch and a bioprosthetic tricuspid valve replacement was performed because the lesions did not allow for any valvular sparing. Because of the proximity between the right coronary ostium and the rupture, a venous aorto-right coronary bypass was performed. The ostium was also closed by the pericardial patch. A peripheral ECMO was implanted at the end of the surgical repair because of a right ventricle dysfunction and a respiratory failure related to severe bilateral pulmonary contusions. A few days later, renal, hepatic and coagulation failures were also noticed, justifying hemodialysis and transfusions. Despite an initial worsening of these five organ failures, the outcome was finally favorable and the patient was discharged 108 days after surgery. A 3-year follow-up revealed a complete recovery of all organ failures. To conclude, we firmly believe that the ECMO can be successfully applied in selected cases of severe right ventricular dysfunction and respiratory failure after cardiac surgery.

Extracorporeal Membrane Oxygenation in Traumatic Injury: An Overview of Utility and Indications

“…In this setting, VV-ECMO may be considered as a lifesaving therapy that helps minimize various post-trauma pneumonectomy physiologic derangements [29]. In other reports, ECMO was used to facilitate successful repair of ruptured mitral papillary muscle [90], resection of post-traumatic ruptured lung abscess with empyema [91], and postoperative cardiorespiratory support following repair of traumatic aorto-right atrial fistula and tricuspid valve rupture [92].…”

“…Other than a mild postpericardiotomy syndrome, the patient recovered from his injury without neurological sequelae [9]. Other scenarios where ECMO was instrumental to satisfactory clinical outcomes following major cardiac trauma includ repair of ruptured mitral papillary muscle [90] and postoperative cardiorespiratory support following repair of traumatic aorto-right atrial fistula and tricuspid valve rupture [92].…”

“…In some cases of unilateral pulmonary or bronchial trauma, either single-lung (e.g., selective ventilation of only one lung) or differential-lung (e.g., each lung managed independently via separate ventilator-tracheal tube circuits) ventilation can be coupled with ECMO to ensure adequate oxygenation while the healing of contralateral traumatic injury is taking place [103]. Following surgical repair of the airway, postoperative continuation of ECMO may be deemed appropriate because (a) healing of operatively repaired tissue may be otherwise affected or compromised [29] or (b) the patient may not be able to immediately wean off the extracorporeal support [92].…”