Echo Case: “Pulsatile” vein in a man after a motor vehicle accident
Authors: Kan Liu, Robert Voelker, Arunpreet Kahlon
Sate University of New York, Upstate Medical University, Syracuse, NY
Kan Liu MD, PhD,
Division of Cardiology, Heart and Vascular Center
Department of Medicine
State University of New York
Upstate Medical University
Syracuse, NY 13202
Tel: 315-464-4535; 315-464-1931 (office)
The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive license on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in HEART editions and any other BMJPGL products to exploit all subsidiary rights.
A 57 year old man with a motor vehicle accident and blunt chest trauma developed refractory hypotension and hypoxia. His external jugular veins were filled, pulsated with an indiscernible waveform. It was difficult to insert a central line into right subclavian vein, because of exceedingly brisk and pulsatile backward blood flow. No murmur was audible in auscultation. No specific cardiac abnormality was indicated in chest X-ray. Creatinine kinase-MB was 30.89 and cTnTwas 0.6. The electrocardiogram (EKG) revealed an intermittent right bundle branch block pattern (Supplementary Figure 1). A subcostal view transthoracic echocardiogram with pulse wave Doppler study was shown in Figure 1A (a color Doppler study was shown in Video 1). A contrast chest computed tomography was shown in Figure 1B.
Which of the following is the most likely diagnosis?
- Acute myocardial infarction
- Pulmonary embolism
- Right ventricular contusion
- Tricuspid regurgitation and ventricular septal defect
Hepatic vein pulse wave Doppler study indicated an abnormal flow pattern characterized by a prominent systolic backward (towards the liver) flow, suggestive of severe tricuspid regurgitation (TR). A color Doppler study in Video1 also confirmed this finding. The contrast in a chest computed tomography created an interventricular connection, which was consistent with a possible traumatic ventricular septal defect (VSD). A transesophgeal echocardiography was performed, and showed chordal rupture of tricuspid valve (TV, Figure 2A and 2B, and Video 2) and VSD (Figure 2C and 2D). He received an urgent surgery to repair TV and ventricular septum, and became hemodynamically stable afterwards.
Due to lack of specific physical/laboratory findings, and coexistence of other urgent surgical issues in trauma patients, timely diagnosis of cardiac injuries is often challenging, which might delay lifesaving surgeries. The most common cardiac injuries in blunt chest trauma are myocardial contusion (particularly in right chambers), valvular injuries (particularly in TV) and aortic (isthmus) damage (1, 2). The symptoms of TR are nonspecific. The murmur from severe TR is usually inaudible, due to quick equalization of pressures between right ventricle and right atrium, and low peak velocity of TR jet. Traumatic VSD occurs less frequently, but is associated with more severe hemodynamic consequence (3). There is no specific EKG finding diagnostic for myocardial contusion, even though sometimes injuries in interventricular septum could cause transient bundle branch change (1, Supplementary Figure 1). The embryologic remnants are rich in the right atrium (RA), such as Chiari network, Eustachian valve, Thebesian valve, and crista terminalis. These anatomic variants can present as highly mobile echogenic tissue (Video 3), and cause diagnostic ambiguity on flail TV leaflets or ruptured papillary muscle (Video 4). In addition, the patients with blunt chest trauma often have other chest wall injuries that result in poor transthoracic echocardiography (TTE) windows, and necessitates transesophageal echocardiography (TEE) for more definitive diagnosis (4). In the present case, TEE indicated that TRwas caused by a completely disrupted and avulsed tricuspid valve apparatus, with a ruptured papillary muscle floated freely in the RA, which was significantly dilated with left deviation of atrial septum (Figure 2A and 2B, and Video 2). Color Doppler study indicated a blood flow across the apical muscular interventricular septum (Figure 2C and 2D), consist with traumatic VSD.
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Supplementary Figure 1.
The electrocardiograms alternate with (A) and without (B) a right buddle branch block pattern.