Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited. Right atrial free wall rupture after blunt chest trauma Elia De Maria, Oscar Gaddi, Alessandro Navazio, Igor Monducci, Giovanni Tirabassi and Umberto Guiducci We report the case of an 18-year-old man, victim of a car accident, presenting with severe hypotension and signs of cardiac tamponade. Transoesophageal echocardiography was suggestive of right atrial free wall rupture. The patient underwent urgent cardiac surgery for repair of right atrial rupture. The immediate clinical outcome was favourable; the patient is in good general condition at 24-month follow-up. The right atrium is rarely involved in cardiac contusion as compared to the right ventricle or other cardiac structures, owing to its anatomical location and direction of physical forces. J Cardiovasc Med 8:946–949 Q 2007 Italian Federation of Cardiology. Journal of Cardiovascular Medicine 2007, 8:946–949 Keywords: blunt injuries, cardiac tamponade, rupture Division of Cardiology, S. Maria Nuova Hospital, Reggio Emilia, Italy Correspondence to Dr Elia De Maria, Divisione di Cardiologia, Arcispedale S. Maria Nuova, Viale Risorgimento 1, 42100 Reggio Emilia, Italy Tel: +39 0522 296434; e-mail: e.demaria@inwind.it Received 20 July 2006 Revised 3 November 2006 Accepted 9 November 2006 Introduction Injuries to the heart and great vessels are often caused by blunt chest trauma. Right atrial rupture is infrequent in thoracic trauma, particularly in the absence of sternal and rib fractures, owing to the anatomical location of the right atrium and direction of physical forces (less than 10% of cardiac injuries). We report the case of an 18-year-old man, victim of a car accident, presenting with severe hypotension and sinus tachycardia. Transoesophageal echocardiography (TEE) was suggestive of right atrial free wall rupture. The patient underwent urgent cardiac surgery, with successful repair of the bleeding tear in the right atrial free wall. Case report An 18-year-old man was admitted to our hospital, shortly after a car accident, presenting with hypotension (80/50 mmHg), sinus tachycardia (125 bpm), oxygen desaturation (85%), and supraventricular ectopic beats. Jugular vein distension and pulsus paradoxus were absent. The patient showed dyspnoea, chest pain, drow- siness and anxiety. The electrocardiogram was normal (Fig. 1). No signs of direct trauma or sternal and rib fractures and no signs of mediastinal enlargement were evident at clinical examination and at chest radiograph. He had multiple facial and cheek fractures. Complete computed tomography scan (head, chest, and abdomen) showed pericardial effusion and local contusion in the inferior regions of the right lung; no evidence of rupture of the thoracic great vessels; no cerebral haemorrhage; and no evidence of abdominal traumatic injury. Trans- thoracic echocardiographic evaluation was immediately performed, because of ongoing haemodynamic instabil- ity without shock, which identified a haemodynamically significant, large pericardial effusion with signs of tamponade (Fig. 2), suggestive of cardiac rupture. For this reason and owing to haemodynamic instability in the absence of other injuries, urgent cardiac surgery was planned. In agreement with the surgeon, TEE was performed to confirm the diagnosis of cardiac rup- ture, so as to avoid inappropriate surgical intervention and for a better anatomical definition of the underlying lesion. TEE confirmed the integrity of the thoracic great vessels, but suggested rupture of the right atrial free wall (Figs 3 and 4). Pericardial drainage was not performed since it is not devoid of risk in unstable patients with suspected large pericardial effusion; in the acute phase, rapid fluid infusion resulted in restoration of haemody- namic stability. Subsequently (about 3 h after injury), the patient underwent cardiac surgery. After tracheal intubation, a median sternotomy was performed; car- diopulmonary bypass was started; and repair of right atrial rupture detected by TEE (a 5-cm tear near the atrioventricular ring) was performed with direct suture. The immediate clinical outcome was favourable; the postoperative recovery was uneventful and the patient was discharged on postoperative day 20. The patient is in good general condition at 24-month follow-up. Discussion Blunt trauma to the heart and great vessels is often caused by motor vehicle crashes and usually results from various mechanisms: compression of the chest with a sudden rise in blood pressure; traction or torsion; acceleration or deceleration; direct injury from a fractured sternum. In clinical series of patients with blunt chest trauma, the incidence of cardiac injuries is around 15%; for injuries to the great vessels it is around 4% [1]. Types of cardiac injuries differ widely: acute tamponade from cardiac rupture; myocardial contusion inducing heart failure; Case report 1558-2027 ß 2007 Italian Federation of Cardiology