Coronary Sinus Rupture Due to Blunt Cardiac Trauma

We present a very rare case of devastating blunt cardiac trauma with large right atrial rupture, contusion of the right atrioventricular groove, and coronary sinus tear. Surgical repair was successfully performed by urgently establishing cardiopulmonary bypass via the femoral vein and artery simultaneously with a median sternotomy. (Level of Difficulty: Intermediate.)

I n June 2021, a 64-year-old man crashed his motorcycle into a vehicle. He was transferred to our hospital after about 1 hour. The primary survey revealed an intact airway. He did not have a traumatic brain injury, but he showed signs of agitation.
His initial vital signs were as follows: systolic blood pressure 120/80 mm Hg, pulse 102/min, respiratory rate 29 breaths per minute, and oxygen saturation of 94% with supplemental oxygen at 2 L/min. He had an unremarkable thoracic contusion and anterior flail chest ( Figure 1A).

DIFFERENTIAL DIAGNOSIS
The patient's clinical condition was diagnosed as a closed chest injury with symptoms of respiratory failure caused by pneumothorax and anterior flail chest.

INVESTIGATIONS
A chest radiograph revealed a large mediastinum, right subcutaneous emphysema, rib fractures, and pneumothorax ( Figure 1B). An electrocardiogram was normal. The patient underwent emergent drainage of the right side of the chest. After the chest drainage, the patient's condition was worse, so chest CT scan and bedside transthoracic echocardiography were indicated. The CT demonstrated sternal fracture ( Figure 2A) and pericardial hemopericardium ( Figure 2B), but no cardiac tamponade was seen by echocardiography (Video 1).

MANAGEMENT
After echocardiography, his vital signs rapidly deteriorated, and his blood pressure was 70/40 mm Hg, so he was taken to the operating room emergently and expeditiously underwent cardiopulmonary bypass

LEARNING OBJECTIVES
To be able to diagnose blunt cardiac trauma quickly in the severe general condition of chest trauma To be able to make the best surgical approach for a very complex heart injury (CPB) via the femoral vein and artery combined with median sternotomy.
While the patient was under CPB without an aortic clamp, we found intact pericardium and a large hemopericardium from 2 large tears on the inferior venous-atrial confluence near the atrioventricular groove ( Figure 3A).  There have been several reports of repair of atrial injury without CPB. 3 However, it is difficult to be sure whether or not the cardiac rupture in those reports was caused by preoperative atrial injury. In the case series by Namai et al, 4

of 5 patients underwent CPB.
The potential uses of CPB are not limited to cardiac chamber injury. CPB has also been used in the repair of concomitant intracardiac injuries. In our study, the patient had acute hemodynamic decompensation and a risk of cardiac arrest, so he underwent CPB through the femoral vein and artery while the median sternotomy was being performed. CPB with a femoral vein-femoral artery access can provide hemodynamic stability and bleeding control before the pericardium is opened. 4,5 Surgical options for the treatment of blunt cardiac trauma include various repair techniques, but the most straightforward option is reasonable in urgent conditions. The cardiac tears can be repaired with simple suture or ligation techniques or patch closure of the large tear. 4 Pledged or nonpledged polypropylene suture repair had been used in several reports. 6,7 Because of the extent of the large laceration  and contusion into the atrioventricular groove with the right coronary artery in the present case, resection of this damaged region was not possible. We decided to reserve and reinforce it with a double Dacron patch. Then, the injured right atrial wall was restored into this double patch.

FOLLOW-UP
Two months post-discharge, the patient came back for a follow-up examination. He could walk independently, was in stable health, and had mild pain at the incision. The patient's chest x-ray showed his lungs and ribs in good condition, and the size and outline of the heart were normal. His echocardiograms revealed good heart function, and his heart valve structures and cardiac chamber size were normal.