Pediatric Cardiac Intensivist Mexican Social Security Institute UMAE No. 34 Monterrey, Nuevo Leon, Mexico
Abstract: Child unintentional injury is still an important cause of morbidity and death for children in the world; congenital anomalies of the mitral valve are the most common cause of mitral regurgitation in children; however, an acquired cause is reported in 35% of the cases. We present a case report of an 8-year-old male patient who suffered a penetrating chest trauma with a sharp object which was accidentally introduced below the xiphoid process and caused a perforation of the anterior leaflet of the mitral valve.
After the accident he was stable and admitted to the emergency room where the injury was cleaned and sutured, he was under 24-hour surveillance and then discharged home. Hours later, the patient presented clinical deterioration with cyanosis and fatigue, so he was re-admitted, and a diagnostic approach was performed. The chest ultrasound reported pericardial and bilateral pleural effusion (left side, 230 ml; right side, 260 ml). Placement of pleural chest tubes and antibiotic therapy was instituted in a specialized care center. Months later he was admitted in multiple occasions in the emergency department due to the progression of the respiratory distress and deterioration of the functional class. The echocardiogram reported severe mitral and moderate tricuspid regurgitation, a decompensated congestive heart failure. Double diuretic and captopril were initiated. The symptoms with significant functional class deterioration continued for 17 months. In a follow-up appointment for surgical assessment the physical examination revealed jugular engorgement, tachypnea (> 50 breaths per minute) with signs of respiratory distress, tachycardia (> 120 beats per minute), a persistent wet cough and orthopnea, bilateral rales on pulmonary auscultation and hepatomegaly (8 cm below the right costal margin).
The multidisciplinary team decided to admit the patient to the PICU for initiation of a diuretic drip (high-dose furosemide) and preoperative evaluation and preparation. The patient underwent elective surgery. The surgical team find a perforation in the anterior leaflet of the mitral valve in the segments A1-A2; the repair was performed, and the valve competency was verified with a hydraulic test. No intervention was performed on the tricuspid valve. A cardiopulmonary bypass time of 87 minutes and an aortic cross-clamping of 36 minutes were registered, no surgical incidents were reported. After the surgery the patient was admitted to the PICU under mechanical ventilation with vasoactive drips of dobutamine (5 mcg/kg/minute) and norepinephrine (0.20 mcg/kg/minute). During his first hours after surgery, he remained hemodynamically stable with adequate urinary output and normal blood lactate. Four hours after the surgery norepinephrine drip was discontinued and 12 hours after surgery elective extubation was performed. He was discharged home 8 days after surgery after antibiotic scheme was completed due to pneumonia.
Repair of the mitral valve in children has improved significantly over the years, although there are several causes of valvular heart disease, traumatic mitral valve regurgitation is a rare and insidious condition; clinical presentation is variable and should be excluded in patients admitted to the emergency department after chest trauma.
