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\begin{document}

\title{Traumatic aortic root rupture leading to acute aortic insufficiency and
acute Type A aortic dissection.}



\author[1]{Subash Nepal}%
\author[1]{Vijay Raj}%
\author[2]{Debanik Chaudhuri}%
\author[1]{Stephany Barreto}%
\affil[1]{SUNY Upstate Medical University}%
\affil[2]{State University of New York Upstate Medical University - University Hospital}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
A 17-year-old male was admitted for the management of multiple fractures
after sustaining blunt thoracic trauma. He was hemodynamically stable
and without any cardiac symptoms. He was admitted with fracture of T4
end plate, manubrium and left first rib, right pulmonary contusion, left
apical pneumothorax and pneumomediastinum. The patient underwent
echocardiography and cardiac CT angiogram for the work up of aortic
injury as the patient had new aortic regurgitation murmur, troponin rise
and RBBB. He was found to have aortic root rupture, type A aortic
dissection and acute severe aortic insufficiency. The patient underwent
surgical aortic valve and root replacement with Bentall procedure with
good outcome.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Motor vehicle accidents are the most common cause of blunt chest trauma
(1). A study showed that 34\% of the fatalities resulting from blunt
chest trauma were from thoracic aortic injury and 80\% at the crash
scene had mortality from exsanguination into the mediastinum (2). While
myocardial contusion leading to troponin leak is the most common injury
and may lead to impaired ventricular systolic function, valve injury is
rare (3).

\textbf{CASE REPORT}

A 17-year old male presented to an outside hospital with blunt trauma to
the chest during a dirt bike accident. He had multiple injuries
including T4 endplate compression fracture, right pulmonary contusion,
left apical pneumothorax, pneumomediastinum, fracture of manubrium and
left first rib. The patient denied any chest pain, palpitations or
shortness of breath. He was hemodynamically stable and not hypoxemic.
Physical examination revealed bounding peripheral pulses with a heart
rate of 105, wide pulse pressure with blood pressure of 122/44 and
tachypnea with respiratory rate of 26. Cardiac auscultation revealed
normal heart sounds and early diastolic murmur in the aortic area. The
patient was initially admitted to the trauma service for the management
of the fractures.

\textbf{Differential diagnosis}

* Traumatic deceleration injury with aortic root rupture

* Traumatic aortic regurgitation

\textbf{Investigations}

Laboratory analysis revealed elevated troponin T of 3.3 ng/mL and EKG
revealed new right bundle branch block. CT angiography of the thorax
revealed prominent aortic sinus (image 1), pneumomediastinum, an aortic
root disruption with Stanford type A dissection with hemopericardium
(image 2) and rupture of the epicardium of the right ventricle and
adventitia of the pulmonary artery. The epicardial hematoma was
contained but the patient had significant intrapericardial bleeding and
clot. TTE revealed dissection flap in the ascending aorta extending into
the right sinus of Valsalva (image 6 and media 1) and severe aortic
regurgitation with holodiastolic flow reversal in the abdominal aorta
(image 3, image 4 and image 5, media 2). Intraoperative TEE revealed
dilated aortic root to 4 cm, dissection flap in the ascending aorta
extending into the right sinus of Valsalva and severe aortic
regurgitation (image 7, media 3).

\textbf{Management}

The patient was tachycardic and was started on low dose esmolol drip.
Midline sternotomy was performed which revealed that the heart and
mediastinum were encased in clot and bulging pericardium which was
removed with pericardiotomy. Direct visual examination revealed an
intact aortic arch with rupture at the sino-tubular ridge extending to
the left coronary ostium. The entire posterior aspect of the ascending
aorta was transected with complete separation of the adventitia, media
and intima with dissecting aneurysm and contained periaortic hematoma
formation. Left coronary ostium was repaired, 23 mm valved St. Jude
conduit was placed, ascending aorta was repaired and both coronary
arteries were re-implanted. Intraoperative TEE post-Bentall procedure
revealed a competent aortic valve and good flow in the coronary
arteries. The patient was discharged home with uneventful postoperative
stay.

\textbf{DISCUSSION}

The aortic root injury is a rare but fatal complication of blunt
thoracic injury if not repaired early. The valvular injury is uncommon
and the aortic valve injury is the most common valvular injury, while
the mitral and tricuspid valves are rarely involved (4). It may lead to
type A aortic dissection and aortic valve disruption, either due to
commissure detachment or rupture of the cusps leading to acute aortic
regurgitation (4). Injuries to the aorta can be classified into four
types: intimal tear only, large intimal flap with intramural hematoma,
pseudoaneurysm and traumatic aortic rupture (TAI) (5). Blunt trauma to
the chest causes injury predominantly to the parts of the heart and
blood vessel that are tethered. The sites of normal anatomic tethering
in aorta are aortic isthmus, which is the segment of proximal descending
aorta at the confluence of mobile arch and fixed descending aorta and
the aortic root, which is the confluence between the mobile heart and
fixed ascending aorta (5). The differential deceleration forces that are
created in these anatomic areas due to blunt chest trauma lead to
shearing of tissues at the junction and make them prone to injury (5). A
normal high aortic root pressure gradient across closed aortic valve
during ventricular diastole further contributes to traumatic aortic
leaflet injury (6).Aortic isthmus is the most common site of TAI
accounting for about 80\% of the cases reported (7). Prognosis is better
with isthmus rupture (19.8\% survival) versus ascending aortic
rupture(4\% survival), due to complex anatomy at the root and survival
depending solely on contained hematoma at that location (8). Thoracic
aortic injury has high mortality and a study has shown that 80\% of
victims died at the scene, underscoring the importance of urgent surgery
(2). Our patient was hemodynamically stable when presented to our center
as he had contained periaortic hematoma and did well after surgery.

CT angiography of the thorax and TEE are the primary diagnostic tools
(9). TEE is beneficial as it helps in bedside evaluation of the extent
of valve injuries, integrity of sino-tubular junction, pericardial and
myocardial injuries (10). It also helps in immediate intraoperative
evaluation of successful valve implantation, good coronary flow and the
integrity of the repaired structures.

Open surgical repair aided by bypass-perfusion technique has been the
preferred modality of repair for the ascending aortic injury. A Bentall
procedure which comprises using a valve conduit to replace the ruptured
aortic valve, aortic root and ascending aorta is the gold standard with
good outcome (11).

\textbf{Follow up}

The patient is doing well after discharge. He denies any chest pain,
palpitation, shortness of breath, syncope or effort intolerance.

\textbf{CONCLUSION}

In conclusion, aortic root injury should be suspected in a patient with
blunt chest trauma. The auscultatory finding of aortic regurgitation
murmur along with radiographic evidence of intrathoracic injury should
be investigated by echocardiography followed by CT of the thorax if
clinically indicated. Urgent surgery for acute aortic root rupture
leading to aortic dissection and severe aortic insufficiency is
lifesaving and has a good outcome.

\textbf{REFERENCES}

1. Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due
to blunt trauma. European journal of cardio-thoracic surgery : official
journal of the European Association for Cardio-thoracic Surgery
2003;23:374-8.

2. Teixeira PG, Inaba K, Barmparas G et al. Blunt thoracic aortic
injuries: an autopsy study. The Journal of trauma 2011;70:197-202.

3. TENZER ML. The Spectrum of Myocardial Contusion: A Review. Journal of
Trauma and Acute Care Surgery 1985;25:620-627.

4. Kan CD, Yang YJ. Traumatic aortic and mitral valve injury following
blunt chest injury with a variable clinical course. Heart
2005;91:568-570.

5. Azizzadeh A, Keyhani K, Miller CC, 3rd, Coogan SM, Safi HJ, Estrera
AL. Blunt traumatic aortic injury: initial experience with endovascular
repair. Journal of vascular surgery 2009;49:1403-8.

6. Obadia JF, Tatou E, David M. Aortic valve regurgitation caused by
blunt chest injury. Br Heart J 1995;74:545-547.

7. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ, Jr. Nonpenetrating
traumatic injury of the aorta. Circulation 1958;17:1086-101.

8. PARMLEY LF, MATTINGLY TW, MANION WC, JAHNKE EJ. Nonpenetrating
Traumatic Injury of the Aorta. Circulation 1958;17:1086-1101.

9. Hiratzka LF, Bakris GL, Beckman JA et al. 2010
ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis
and management of patients with Thoracic Aortic Disease: a report of the
American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines, American Association for Thoracic
Surgery, American College of Radiology, American Stroke Association,
Society of Cardiovascular Anesthesiologists, Society for Cardiovascular
Angiography and Interventions, Society of Interventional Radiology,
Society of Thoracic Surgeons, and Society for Vascular Medicine.
Circulation 2010;121:e266-369.

10. Sun X, Hong J, Lowery R et al. Ascending aortic injuries following
blunt trauma. Journal of cardiac surgery 2013;28:749-55.

11. German DS, Shapiro MJ, Willman VL. Acute aortic valvular
incompetence following blunt thoracic deceleration injury: case report.
The Journal of trauma 1990;30:1411-2.\selectlanguage{english}
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