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

Abstract

BackgroundIsolated 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 reportA 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.MethodsA 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.ResultsForty-five reports comprising seventy-five (n = 75) cases of IRAR.ConclusionIRAR 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.

“I Tripped and Broke My Heart”: A Case Report of Right Atrial Rupture

“…3 The mechanism for IRAR in our case is unclear but is likely related to hydraulic and deceleration forces potentially occurring at a particular moment in the cardiac cycle during the patient's fall. 3 Comotio cordis, for example, requires a blow to the heart at a very specific period during cardiac repolarization. Such a temporal coincidence may also be required in RA rupture but can only be hypothesized.…”

“…2e4 RA rupture was reported to have occurred in 35 of 273 cases of cardiac rupture in a series of cases of nonpenetrating cardiac trauma by Parmley et al 2 Isolated right atrial rupture (IRAR) is a rare injury, most commonly resulting from blunt chest trauma. Maraqa et al 3 cited an incidence of IRAR of 0.2% to 0.5%. 3 In their review of reported cases since 1955, they identified 75 patients with IRAR.…”

“…Maraqa et al 3 cited an incidence of IRAR of 0.2% to 0.5%. 3 In their review of reported cases since 1955, they identified 75 patients with IRAR. Most cases (92%) occurred secondary to motor vehicle accidents.…”

“…Although cases of RA rupture have been reported to occur from falls, these were sustained from significant heights with high impact velocities and associated extracardiac trauma, such as pelvic fractures, arterial ruptures, and mesenteric injury. 3,5,6 Most reported cases of IRAR occur from blunt chest trauma from motor vehicle accidents, with the direct impact to the chest as the mechanism for rupture. 3 The mechanism for IRAR in our case is unclear but is likely related to hydraulic and deceleration forces potentially occurring at a particular moment in the cardiac cycle during the patient's fall.…”

“…3,5,6 Most reported cases of IRAR occur from blunt chest trauma from motor vehicle accidents, with the direct impact to the chest as the mechanism for rupture. 3 The mechanism for IRAR in our case is unclear but is likely related to hydraulic and deceleration forces potentially occurring at a particular moment in the cardiac cycle during the patient's fall. 3 Comotio cordis, for example, requires a blow to the heart at a very specific period during cardiac repolarization.…”