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Unexpected traumatic rupture of left atrium mimicking aortic rupture.

Alameddine AK, Alimov VK, Alvarez C, Rousou JA - J Emerg Trauma Shock (2014)

Bottom Line: As in the present case, the patient eventually died from associated extrathoracic injuries.Subtle radiological features can help distinguish aortic thoracic injury as illustrated in this patient.These factors may be useful to the practicing surgeon in deciding surgical approach.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiac Surgery, Baystate Medical Center, Springfield and Tufts School of Medicine, Boston, Massachusetts, USA.

ABSTRACT
Left atrial (LA) rupture is rare following blunt chest injury. We describe a case of blunt LA rupture that was treated surgically. This report is intended to alert practitioners for a need of a close multiple disciplinary collaborations among them for optimal management of patients with this type of trauma; because other non-cardiac injuries involving the head, abdomen, or extremities are considered covariates for in-hospital mortality. As in the present case, the patient eventually died from associated extrathoracic injuries. The diagnosis of LA rupture is by exclusion. However, the initial radiological reading may be misinterpreted, because this injury can easily be mistaking for an aortic rupture. The final reappraisal of the chest imaging studies should be interpreted by a skilled radiologist to avoid misdiagnosis. Subtle radiological features can help distinguish aortic thoracic injury as illustrated in this patient. These factors may be useful to the practicing surgeon in deciding surgical approach.

No MeSH data available.


Related in: MedlinePlus

(a) Initial AP portable chest radiograph shows widening of the superior mediastinum (wide right paratracheal stripe, loss of aortic knob contour in a young patient) and extension of blood into the left apical extrapleural space (arrows), all consistent with a mediastinal hematoma (b) Axial enhanced CT images on day of injury through the aortic isthmus show a curvilinear area of enhancement (arrows) extending from the isthmus, consistent with a bronchial or intercostal artery. Appearance unlikely to represent aortic pseudoaneurysm (c) Coronal and sagittal reconstructions confirm curvilinear/tubular areas of enhancement in the vicinity of the aortic isthmus
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Figure 1: (a) Initial AP portable chest radiograph shows widening of the superior mediastinum (wide right paratracheal stripe, loss of aortic knob contour in a young patient) and extension of blood into the left apical extrapleural space (arrows), all consistent with a mediastinal hematoma (b) Axial enhanced CT images on day of injury through the aortic isthmus show a curvilinear area of enhancement (arrows) extending from the isthmus, consistent with a bronchial or intercostal artery. Appearance unlikely to represent aortic pseudoaneurysm (c) Coronal and sagittal reconstructions confirm curvilinear/tubular areas of enhancement in the vicinity of the aortic isthmus

Mentions: A 32-year-old man sustained multiple injuries following a high-speed dirt bike collision at 70 mph. On initial resuscitation in the emergency department (ED) his systolic blood pressure was < 50 mmHg. The extended Focused Assessment with Sonography for Trauma examination (eFAST) revealed pericardial effusion. A chest radiograph showed a widened superior mediastinum and left pneumothorax. His other injuries included bilateral lung contusions, mid sternal transverse fracture, open fractures of left radius/ulna and left tibial/fibular shafts, and multiple cerebral contusions. The patient responded to intravenous fluids administration and stabilized by the trauma team (blood pressure 110/60 mmHg, pulse 95 beats per minute with normal respirations). He was sent to the radiography suite after a left thoracostomy tube was inserted. The initial interpretation of the chest computed tomographic (CT) angiography could not rule out an aortic injury.[see Figure 1a-c] However, the re-evaluation of the CT by the radiologist revealed significant mediastinal hematoma but with an intact thoracic aorta. Because the patient became suddenly hemodynamically unstable and the eFAST was positive, he was taken to the operating room for emergent median sternotomy to determine the source of mediastinal hemorrhage. The time between the ED arrival to the sternotomy incision was approximatly 2 hours. Exploration revealed a large amount of blood in the pericardial cavity which seemed to be coming posterior to the aortic root. Conclusive evaluation of this area was possible onlsy when cardiopulmonary bypass (CBP) was established. A transverse tear of 2.5 cm in length was identified in the roof of the left atrium (LA) [Figure 2]. The tear was closed with simple suture technique using pledgetted 4-0 Prolene. The CPB time was 45 minutes. His hospital course was complicated by refractory multiorgan failure which led to his death 17 days after the accident. A chest CT scan obtained 1 day before patient expired showed an unchanged curvilinear area of enhancement adjacent to the left bronchus [Figure 3].


Unexpected traumatic rupture of left atrium mimicking aortic rupture.

Alameddine AK, Alimov VK, Alvarez C, Rousou JA - J Emerg Trauma Shock (2014)

(a) Initial AP portable chest radiograph shows widening of the superior mediastinum (wide right paratracheal stripe, loss of aortic knob contour in a young patient) and extension of blood into the left apical extrapleural space (arrows), all consistent with a mediastinal hematoma (b) Axial enhanced CT images on day of injury through the aortic isthmus show a curvilinear area of enhancement (arrows) extending from the isthmus, consistent with a bronchial or intercostal artery. Appearance unlikely to represent aortic pseudoaneurysm (c) Coronal and sagittal reconstructions confirm curvilinear/tubular areas of enhancement in the vicinity of the aortic isthmus
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4231269&req=5

Figure 1: (a) Initial AP portable chest radiograph shows widening of the superior mediastinum (wide right paratracheal stripe, loss of aortic knob contour in a young patient) and extension of blood into the left apical extrapleural space (arrows), all consistent with a mediastinal hematoma (b) Axial enhanced CT images on day of injury through the aortic isthmus show a curvilinear area of enhancement (arrows) extending from the isthmus, consistent with a bronchial or intercostal artery. Appearance unlikely to represent aortic pseudoaneurysm (c) Coronal and sagittal reconstructions confirm curvilinear/tubular areas of enhancement in the vicinity of the aortic isthmus
Mentions: A 32-year-old man sustained multiple injuries following a high-speed dirt bike collision at 70 mph. On initial resuscitation in the emergency department (ED) his systolic blood pressure was < 50 mmHg. The extended Focused Assessment with Sonography for Trauma examination (eFAST) revealed pericardial effusion. A chest radiograph showed a widened superior mediastinum and left pneumothorax. His other injuries included bilateral lung contusions, mid sternal transverse fracture, open fractures of left radius/ulna and left tibial/fibular shafts, and multiple cerebral contusions. The patient responded to intravenous fluids administration and stabilized by the trauma team (blood pressure 110/60 mmHg, pulse 95 beats per minute with normal respirations). He was sent to the radiography suite after a left thoracostomy tube was inserted. The initial interpretation of the chest computed tomographic (CT) angiography could not rule out an aortic injury.[see Figure 1a-c] However, the re-evaluation of the CT by the radiologist revealed significant mediastinal hematoma but with an intact thoracic aorta. Because the patient became suddenly hemodynamically unstable and the eFAST was positive, he was taken to the operating room for emergent median sternotomy to determine the source of mediastinal hemorrhage. The time between the ED arrival to the sternotomy incision was approximatly 2 hours. Exploration revealed a large amount of blood in the pericardial cavity which seemed to be coming posterior to the aortic root. Conclusive evaluation of this area was possible onlsy when cardiopulmonary bypass (CBP) was established. A transverse tear of 2.5 cm in length was identified in the roof of the left atrium (LA) [Figure 2]. The tear was closed with simple suture technique using pledgetted 4-0 Prolene. The CPB time was 45 minutes. His hospital course was complicated by refractory multiorgan failure which led to his death 17 days after the accident. A chest CT scan obtained 1 day before patient expired showed an unchanged curvilinear area of enhancement adjacent to the left bronchus [Figure 3].

Bottom Line: As in the present case, the patient eventually died from associated extrathoracic injuries.Subtle radiological features can help distinguish aortic thoracic injury as illustrated in this patient.These factors may be useful to the practicing surgeon in deciding surgical approach.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiac Surgery, Baystate Medical Center, Springfield and Tufts School of Medicine, Boston, Massachusetts, USA.

ABSTRACT
Left atrial (LA) rupture is rare following blunt chest injury. We describe a case of blunt LA rupture that was treated surgically. This report is intended to alert practitioners for a need of a close multiple disciplinary collaborations among them for optimal management of patients with this type of trauma; because other non-cardiac injuries involving the head, abdomen, or extremities are considered covariates for in-hospital mortality. As in the present case, the patient eventually died from associated extrathoracic injuries. The diagnosis of LA rupture is by exclusion. However, the initial radiological reading may be misinterpreted, because this injury can easily be mistaking for an aortic rupture. The final reappraisal of the chest imaging studies should be interpreted by a skilled radiologist to avoid misdiagnosis. Subtle radiological features can help distinguish aortic thoracic injury as illustrated in this patient. These factors may be useful to the practicing surgeon in deciding surgical approach.

No MeSH data available.


Related in: MedlinePlus