Isolated Right Atrial Rupture From Blunt Chest Trauma in Motor Vehicle Collisions: Mechanisms of Injury and Outcomes.

ABSTRACT: Isolated right atrial rupture after nonpenetrating blunt chest trauma is rare, and very few cases have been reported in the literature. Isolated right atrial rupture is a diagnostic challenge in these patients, who are mostly victims of motor vehicle collisions. The clinical presentation is heterogeneous and can vary depending on rupture location and size. The anatomical sites mostly involved are the appendage and the free wall followed by the superior and inferior vena cava junctions. The present case study shows a fatal isolated rupture of the right atrial appendage in a victim of a motor vehicle collision. At the emergency room, a computed tomography scan revealed a severe pericardial blood effusion, and pericardiocentesis was promptly performed. Unfortunately, the patient suddenly worsened just before cardiac surgery. Autopsy findings showed a cardiac tamponade due to a linear laceration 1.8 cm in length on the right atrial appendage. No other relevant injuries were observed. A prompt diagnosis of isolated right atrial rupture can be crucial for victims of blunt chest trauma with unexplained hypotension or hemodynamic instability to improve their chances of survival. Medicolegal issues can be raised mainly related to delayed diagnosis. Once a cardiac rupture is suspected, the injury repair is essential to achieve the best outcome.

Percutaneous management of left atrial appendage perforation during device closure.

A 76-year-old male patient was admitted for percutaneous left atrial appendage (LAA) closure because of chronic atrial fibrillation and a history of gastrointestinal bleeding under oral anticoagulation. The procedure was complicated by perforation of the LAA with the lobe of the closure device being placed in the pericardial space. Keeping access to the pericardial space with the delivery sheath, the LAA closure device was replaced by an atrial septal defect closure device to seal the perforation. Then the initial LAA closure device was reimplanted in a correct position. Needle pericardiocentesis was required but the subsequent course was uneventful.

Recurrent pericardial effusion caused by pacemaker lead perforation and warfarin therapy at seven years after implantation.

A 66-year-old man was implanted with a pacemaker. Seven years after implantation he was admitted due to cardiogenic cerebral embolism and warfarin therapy was introduced. After that, he suffered recurrent pericardial effusion for unexplained reasons. An exploratory thoracotomy revealed that the screw of the atrial lead had penetrated through the right auricular appendage wall.

Survivor of Right Atrial Appendage Rupture Following Blunt Chest Trauma.

A 20-year-old woman presented to our trauma center with cardiac rupture after a motor vehicle collision. Our patient was the restrained driver in a high-speed collision. She arrived without external evidence of trauma but in obvious distress with tachycardia, tachypnea, and hypotension. Initial FAST was negative and chest x-ray; however, second FAST was equivocal for pericardial fluid. Computed tomography demonstrated a large hemopericardium, suspicious for cardiac injury. She underwent emergent operative exploration with a median sternotomy. A 1 cm right atrial appendage avulsion was identified and repaired primarily. She recovered uneventfully and was discharged home. Survival of blunt cardiac rupture is extremely rare and can occur in the absence of any external signs of trauma. Surgeons should maintain clinical suspicion for blunt cardiac injury in unstable trauma patients with deceleration injuries. Injury to the low-pressure right atrium likely contributed to her ability to survive transport to a trauma center.

Right atrial perforation at the end of an atrial fibrillation ablation procedure.

A 74-year-old man with chronic atrial fibrillation underwent ablation under conscious sedation. After sheath removal from the left atrium, the patient flexed his thighs, resulting in a 'foetal position' developing tamponade due to an right atrial (RA) appendage perforation from sheath migration. This illustrates the importance of close monitoring during sedation weaning, recommending removal of all sheaths prior to sedation withdrawal.

Isolated right atrial rupture from blunt trauma: a case report with systematic review of a lethal injury.

BACKGROUND: Isolated right atrial rupture (IRAR) from blunt chest trauma is rare. There are no physical exam findings and non-invasive testing specific to the condition, which result in diagnostic delays and poor outcomes. We present a case of IRAR along with a systematic review of similar cases in the literature. CASE REPORT: A 23-year-old male presented following a motor vehicle accident (MVA). He was bradycardic and hypotensive during transportation; and required intubation. There were contusions along the right chest wall with clear breath sounds, and no jugular venous distension, muffled heart sounds. Hemodynamic status progressively worsened, ultimately leading to his death. However, no external sources of bleeding or evidence of cardiac tamponade was found. METHODS: A search of PubMed, Ovid, and the Cochrane Library using: (Blunt OR Blunt trauma) AND (Laceration OR Rupture OR Tear) AND (Right Atrium OR Right Atrial). Articles were included if they were original articles describing cases of IRAR. RESULTS: Forty-five reports comprising seventy-five (n = 75) cases of IRAR. CONCLUSION: IRAR most commonly occurs following MVAs as the result of blunt chest trauma. Rupture occurs at four distinct sites and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires a high index of suspicion, as patients' hemodynamics can rapidly deteriorate. The presentations vary depending on multiple factors including rupture size, pericardial integrity, and concomitant injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding source. A pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are favourable with timely recognition and prompt surgical intervention.

Totally Thoracoscopic Closure of the Left Atrial Appendage.

The left atrial appendage (LAA) is a major site of clot formation in atrial fibrillation. Stand-alone thoracoscopic LAA complete closure can decrease stroke risk and may be an alternative to life-long oral anticoagulation. This report describes a technique for totally thoracoscopic LAA exclusion with an epicardial clip device. This approach provides a safe and likely more effective alternative to LAA management than other endocardial devices.

Percutaneous Management of Left Atrial Appendage Perforation: Keep Calm and Think Fast.

Left atrial appendage (LAA) perforation is a possible complication not only after release of the closure device, but also during the diagnostic phase due to sheath positioning in the LAA. We present an 83-year-old woman with permanent atrial fibrillation and high thromboembolic and bleeding risk who was admitted for elective percutaneous LAA closure. During angiographic study, she suddenly became hypotensive. Heart perforation with leakage of contrast in the pericardial space was evident and imaging confirmed cardiac tamponade. Rapid release of the closure device and pericardial evacuation allowed the operators to successfully manage the cardiac tamponade and avoid a surgical option.

Surgical perspective of percutaneous device closure of atrial septal defect.

Background Percutaneous device closure of an ostium secundum atrial septal defect is associated with excellent outcomes and cosmetic results but at the cost of occasional serious and sometimes fatal complications as well as lifelong follow-up. Surgical intervention is required in cases of device-related complications, which carries a slightly higher risk compared to primary closure of an atrial septal defect. We present a surgical perspective of device closure of atrial septal defect. Methods Our database was searched over 4 years for complications related to percutaneous device closure of atrial septal defect, which required surgical retrieval of the device and closure of the defect. We identified 14 cases that required surgical intervention. Results The median age of the 14 patients was 18 years (range 4-58 years). The size of the defect ranged from 15 to 40 mm (median 30 mm). Device embolization into any part of the cardiovascular system ( n = 8) was the most common complication, followed by malalignment of the device ( n = 5). One patient had left atrial appendage perforation causing pericardial effusion and cardiac tamponade, and underwent surgical repair. The other 13 patients underwent removal of the device and atrial septal defect closure. One patient developed severe mitral regurgitation requiring mitral valve replacement. There was no mortality. Conclusion Although the incidence of device-related complications may be small, they carry a high risk of death or long-term morbidity, even with a small atrial septal defect, unlike primary surgical closure of isolated atrial septal defect.

Current of injury predicts adequate active lead fixation in permanent pacemaker/defibrillation leads.

OBJECTIVES: The aim of this study was to determine whether current of injury can guide adequate placement of active-fixation pacing leads. BACKGROUND: Active-fixation leads cause injury to the myocardium at the time of fixation, manifested as a current of injury (COI) that may result in acute elevation of pacing thresholds. The relationship of COI to subsequent improvement in pacing thresholds is not clear. METHODS: Sixty-five patients undergoing active-fixation lead implantation were enrolled. Current of injury was characterized as the duration of the intracardiac electrogram (EGM) and the magnitude of ST-segment elevation. Pacing parameters were measured up to 10 min after fixation. RESULTS: A total of 96 active-fixation leads were studied, and 76 leads had a current of injury. From baseline to the time of fixation, the duration of the intracardiac EGM in ventricular leads increased from 150 +/- 31 ms to 200 +/- 25 ms (p < 0.001), and the ST-segment increased from 1.5 +/- 0.2 mV to 10.0 +/- 2.0 mV (p < 0.001), with subsequent improvement in pacing thresholds from 1.5 +/- 0.4 V to 0.8 +/- 0.3 V (p < 0.001) at 10 min. Atrial leads with a current of injury had similar findings. Of the 20 leads without a COI, 5 dislodged acutely and 15 had high pacing thresholds at 10 min, requiring repositioning. CONCLUSIONS: The development of a COI indicates that within 10 min of fixation, pacing threshold will return to an acceptable range even if the initial measurement is high. Conversely, without a COI, lead fixation is not adequate and the lead should be repositioned.

Blunt traumatic left atrial appendage rupture and cardiac herniation.

A 42-year-old man sustained blunt thoracic trauma after a motor vehicle accident. He underwent an urgent operation. Operative findings included a large hematoma, a 4-cm tear in the left atrial appendage, and a long pleuropericardial rupture along the right phrenic nerve. We repaired the left atrial appendage without cardiopulmonary bypass, and closed the pericardial defect primarily. The patient recovered fully and was discharged on the 6th postoperative day.

Late atrial appendage perforation from a pacemaker lead pacemaker complication.

Lead perforation is a rare complication of device implantation, varying between 0.3% and 1%, although the prevalence may be higher. Late lead perforations (>1 month after implantation) are believed to be very rare. We describe the successful treatment of a 65-year-old man with late cardiac perforation due to the pacemaker active fixation lead after an uneventful implantation.

Percutaneous catheter-based left atrial appendage ligation and management of periprocedural left atrial appendage perforation with the LARIAT suture delivery system.

We report an 88-year-old male with coronary artery disease, previously placed left main coronary artery drug-eluting stent, and atrial fibrillation unable to tolerate anticoagulation with warfarin in addition to dual antiplatelet therapy who underwent percutaneous catheter-based ligation of the left atrial appendage. During the procedure, left atrial appendage perforation occurred with resultant pericardial effusion. The novel LARIAT suture delivery system (SentreHEART) allowed immediate and definitive management of this complication and effective ligation of the left atrial appendage. Prospective studies are needed to determine whether this is a safe and effective method for thromboembolism prophylaxis in patients with atrial fibrillation, but its novel design incorporates an immediate resolution to the most-feared complication of catheter-based left atrial appendage manipulation while effectively excluding the left atrial appendage via suture ligation.