Coronary sinus and atrioventricular groove avulsion after motor vehicle crash
A 17-year-old male presented to our hospital after a high-speed motor vehicle crash that required prolonged extrication followed by rapid-sequence intubation. He required one unit of packed red blood cells for hypotension. On arrival to the trauma bay, he was normotensive with a heart rate of 70 beats/min. A 36-French chest tube was placed for left hemothorax. Initially, a sample of 1500 ml of blood was evacuated before output ceased. Patient remained hemodynamically stable. A focused abdominal sonogram for trauma (FAST) was negative for fluid in the abdominal and cardiac windows.\nFull-body computed tomography (CT) scan revealed a retained left hemothorax and subtle irregularity of the proximal descending aorta concerning for aortic disruption []. Following imaging, the chest tube resumed high output requiring further resuscitation and emergent exploration. Cardiothoracic surgery was called to the operating room due to concern for aortic disruption. Upon exploring the left chest through a thoracotomy, there was no active hemorrhage in the left pleural space. The aorta was uninjured. The pericardium was traumatically ruptured, but the avulsed and skeletonized left phrenic nerve was intact [].\nControl of bleeding was attempted by placing a large sheet of surgifoam along the atrioventricular groove at the base of the heart. Shortly thereafter, the heart distended and the patient arrested requiring emergent cardiopulmonary bypass achieved by cannulating the left apex and right atrium. Further, inspection revealed avulsion tears of the coronary sinus extending to the inferior vena cava. There was a separate avulsion of the right atrial appendage near the right coronary artery. Avulsion tears were repaired using pledgeted polypropylene sutures carefully avoiding adjacent coronary arteries. Excellent hemostasis was achieved and cardiopulmonary bypass was weaned. Post-operatively the patient recovered without further cardiac events and has been discharged from rehabilitation.