PMC8160429_01
Chest X-ray (A) and Contrast-enhanced computed tomography (B,C) showed mild cardiomegaly, interstitial pulmonary edema, and bilateral pulmonary contusions.
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F1
On the day of admission, bilateral pulmonary infiltrates and cardiomegaly were noted on the chest X-ray (Figure 1A). CT scan showed pulmonary contusions, hemopneumothorax, renal laceration, and multiple bone fractures, including ribs, pelvis and lumbar vertebra. Cardiac severe injuries, such as aortic dissection, aortic aneurysm, and cardiac tamponade, were not found (Figures 1B,C).
A pigtail catheter was advanced for the aortic and pulmonary angiogram. (A) Aortic angiogram showed severe diastolic retrograde flow (white arrow) from the AAO to the LV. No enlarged or ruptured bronchial arteries, which may be responsible for hemoptysis, were found to originate from the supra-aortic branches or DAO. (B) Pulmonary angiogram showed no pulmonary vascular abnormalities responsible for hemoptysis, such as post-traumatic PA pseudoaneurysms and pulmonary arteriovenous malformations. AAO, ascending aorta; DAO, descending aorta; LV, left ventricle; PA, pulmonary artery.
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F2
However, the aortic angiogram unexpectedly showed wide-open aortic insufficiency (Figure 2).
Preoperative transesophageal echocardiography (TEE) showed free-flow aortic regurgitation (black asterisk), which is caused by a fissure (white arrow) formed between the flailed right coronary cusp and non-coronary cusp, on the long-axis view (A), short-axis view (B) and five-chamber view (C). Postoperative TEE showed well-functioning new valves without regurgitation (D-F). N, non-coronary cusp; R, right coronary cusp; L, left coronary cusp; LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.
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F3
A transesophageal echocardiogram (TEE) was then obtained and revealed mild left heart dilatation and severe eccentric aortic regurgitation due to flail non-coronary cusp (NCC) and right coronary cusp (RCC) (Figures 3A-C). Postoperative TEE showed well-functioning new valves without regurgitation (Figures 3D-F).
A timeline of the patient's diagnosis and treatment process. CT, computed tomography; TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; LVEF, left ventricular ejection fraction.
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F4
The timeline illustrating the diagnostic workup and therapeutic process is shown in Figure 4.