Solving the impossible. Penetrating cardiac injuries, a case series of diagnostic workup and management
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Abstract
For a long time, any heart-based injury was an off-limits area for surgeons; a patient with a traumatic cardiac injury was doomed to die. Little more than one hundred years have passed since the first surgical correction of a penetrating cardiac injury and there is still a high rate of mortality, despite the medical advances. We present the case of 6 patients with penetrating cardiac injuries that were repaired at a third level hospital of Mexico, alongside relevant findings on the literature about the topic. From 2019 to 2020, an incidence of 6 patients with penetrating cardiac injuries was present; all men aged 30 years or older. The etiology of 4 (67%) patients was stab wounds and 2 (33%) gunshot wounds. Left anterolateral thoracotomy was used on 5 (83%) patients and midline sternotomy on 1 (17%) patient. 2 (33%) injuries on the left ventricle presented along with coronary arteries injuries. Left ventricle and right atrium injuries presented each 50% of mortality. The mortality was of 33%, 1 patient died due to intraoperative complications and another one due to massive cerebral infarction and polyuric syndrome because of diabetes insipidus. There is a long path ahead of the surgical field on this topic and further to be analyzed. An excellent tool for cardiac tamponade diagnosis due to penetrating cardiac injuries is cardiac ultrasound, therefore it should be used on every hemodynamic unstable patient in the context of PCI. Definitively, time is of the essence, and the survival of patients depends on immediate transport to a hospital and an opportune surgical intervention.
References
Abou-Leila, A. and Voronov, G. (2017) ‘The journey of harmless bullet: The perioperative care of penetrating cardiac injury’, Anesthesia: Essays and Researches, 11(3), p. 790. doi: 10.4103/0259-1162.194578.
Albadani, M. N. and Alabsi, N. A. (2013) ‘Management of Chest Injuries: A prospective study’, Yemeni Journal for Medical Sciences, 5, pp. 23–27. Available at: https://ust.edu/ojs/index.php/yjmp/article/view/257.
de Araújo, A. O. et al. (2018) ‘Fatal cardiac trauma in the city of manaus, Amazonas State, Brazil’, Revista do Colegio Brasileiro de Cirurgioes, 45(4), pp. 1–8. doi: 10.1590/0100-6991e-20181888.
Asensio, J. A. et al. (1998) ‘One Hundred Five Penetrating Cardiac Injuries’, The Journal of Trauma: Injury, Infection, and Critical Care, 44(6), pp. 1073–1082. doi: 10.1097/00005373-199806000-00022.
Asensio, J. A. et al. (2009) ‘Penetrating Cardiac Injuries: A Historic Perspective and Fascinating Trip Through Time’, Journal of the American College of Surgeons. American College of Surgeons, 208(3), pp. 462–472. doi: 10.1016/j.jamcollsurg.2008.12.011.
Baker, L., Almadani, A. and Ball, C. G. (2015) ‘False negative pericardial Focused Assessment with Sonography for Trauma examination following cardiac rupture from blunt thoracic trauma: a case report’, Journal of Medical Case Reports. Journal of Medical Case Reports, 9(1), p. 155. doi: 10.1186/s13256-015-0640-6.
Ball, C. G. et al. (2009) ‘A Caveat to the Performance of Pericardial Ultrasound in Patients With Penetrating Cardiac Wounds’, Journal of Trauma: Injury, Infection & Critical Care, 67(5), pp. 1123–1124. doi: 10.1097/TA.0b013e3181b16f30.
Bamous, M. et al. (2016) ‘Evaluation of penetrating cardiac stab wounds’, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 24(1), p. 6. doi: 10.1186/s13049-015-0190-3.
Bellister, S. A., Dennis, B. M. and Guillamondegui, O. D. (2017) ‘Blunt and Penetrating Cardiac Trauma’, Surgical Clinics of North America. Elsevier Inc, 97(5), pp. 1065–1076. doi: 10.1016/j.suc.2017.06.012.
Besir, Y., Gokalp, O. and Eygi, B. (2015) ‘Choice of Incision in Penetrating Cardiac Injuries: Which one we must prefer? Thoracotomy or Sternotomy’, Turkish Journal of Trauma and Emergency Surgery, 21(4), pp. 266–270. doi: 10.5505/tjtes.2015.52882.
Burlew, C. C. et al. (2012) ‘Western Trauma Association Critical Decisions in Trauma’, Journal of Trauma and Acute Care Surgery, 73(6), pp. 1359–1363. doi: 10.1097/TA.0b013e318270d2df.
Butts, C. A. et al. (2019) ‘Sutureless Repair of a Full-Thickness Cardiac Stab Wound Adjacent to the Right Coronary Artery Using Evarrest® Patch’, The American Surgeon, 85(8), pp. 419–420. doi: 10.1177/000313481908500820.
Campbell, N. C. et al. (1997) ‘Review of 1198 cases of penetrating cardiac trauma’, British Journal of Surgery, 84(12), pp. 1737–1740. doi: 10.1002/bjs.1800841225.
Chiara, O. et al. (2018) ‘A systematic review on the use of topical hemostats in trauma and emergency surgery’, BMC Surgery. BMC Surgery, 18(1), pp. 1–20. doi: 10.1186/s12893-018-0398-z.
Clarke, D. L. et al. (2011) ‘Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa’, The Journal of Thoracic and Cardiovascular Surgery. The American Association for Thoracic Surgery, 142(3), pp. 563–568. doi: 10.1016/j.jtcvs.2011.03.034.
Co, S. J. et al. (2011) ‘Role of Imaging in Penetrating and Blunt Traumatic Injury to the Heart’, RadioGraphics, 31(4), pp. E101–E115. doi: 10.1148/rg.314095177.
Dehghani, P. et al. (2009) ‘Post-traumatic ventricular septal defects--review of the literature and a novel technique for percutaneous closure’, J Invasive Cardiol, 21(9), pp. 483–7.
Durso, A. M., Caban, K. and Munera, F. (2015) ‘Penetrating Thoracic Injury’, Radiologic Clinics of North America. Elsevier Inc, 53(4), pp. 675–693. doi: 10.1016/j.rcl.2015.02.010.
Embrey, R. (2007) ‘Cardiac Trauma’, Thoracic Surgery Clinics, 17(1), pp. 87–93. doi: 10.1016/j.thorsurg.2007.02.002.
Flécher, E., Leguerrier, A. and Nesseler, N. (2020) ‘An odyssey of suturing cardiac wounds: Lessons from the past’, Journal of Cardiac Surgery, 35(7), pp. 1597–1599. doi: 10.1111/jocs.14675.
Góes Junior, A. M. de O. et al. (2019) ‘O uso da tomografia computadorizada na triagem da lesão cardíaca penetrante.’, Revista do Colégio Brasileiro de Cirurgiões, 46(3), pp. 1–8. doi: 10.1590/0100-6991e-20192154.
Gunn, M. L. et al. (2014) ‘Current concepts in imaging evaluation of penetrating transmediastinal injury’, Radiographics, 34(7), pp. 1824–1841. doi: 10.1148/rg.347130022.
Hanpeter, D. E. et al. (2000) ‘Helical computed tomographic scan in the evaluation of mediastinal gunshot wounds’, Journal of Trauma - Injury, Infection and Critical Care, 49(4), pp. 689–695. doi: 10.1097/00005373-200010000-00017.
Hommes, M. et al. (2013) ‘Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma’, British Journal of Surgery, 100(11), pp. 1454–1458. doi: 10.1002/bjs.9241.
Ivatury, R. R. and Rohman, M. (1992) ‘Penetrating cardiac trauma’, The Annals of Thoracic Surgery, 54(6), pp. 1247–1248. doi: 10.1016/0003-4975(92)90121-J.
Jones, T. S. et al. (2014) ‘Emergency department pericardial drainage for penetrating cardiac wounds is a viable option for stabilization’, The American Journal of Surgery. Elsevier Inc, 207(6), pp. 931–934. doi: 10.1016/j.amjsurg.2013.08.042.
Kaljusto, M.-L. et al. (2015) ‘Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma center’, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. ???, 23(1), p. 41. doi: 10.1186/s13049-015-0125-z.
Kang, N. et al. (2009) ‘Penetrating cardiac injury: Overcoming the limits set by Nature’, Injury, 40(9), pp. 919–927. doi: 10.1016/j.injury.2008.12.008.
Karigyo Toshiyuki, C. J. et al. (2013) ‘Trauma cardíaco penetrante’, Rev. Med. Res., 15(3), pp. 198–206.
Khorsandi, M. et al. (2015) ‘Major cardiothoracic trauma: Eleven-year review of outcomes in the North West of England’, The Annals of The Royal College of Surgeons of England, 97(4), pp. 298–303. doi: 10.1308/003588415X14181254789169.
Kim, J. S. et al. (2020) ‘Penetrating injury to the cardiac box’, Journal of Trauma and Acute Care Surgery, 89(3), pp. 482–487. doi: 10.1097/TA.0000000000002808.
Kong, V. Y. et al. (2015) ‘Penetrating cardiac injuries and the evolving management algorithm in the current era’, Journal of Surgical Research. Elsevier Inc, 193(2), pp. 926–932. doi: 10.1016/j.jss.2014.09.027.
Lee, H. et al. (2009) ‘New-onset heart failure caused by spontaneous papillary muscle rupture: Diagnosis with dual-source computed tomographic coronary angiography’, The Journal of Thoracic and Cardiovascular Surgery. The American Association for Thoracic Surgery, 137(1), pp. e19–e21. doi: 10.1016/j.jtcvs.2008.02.054.
Lichtenberger, J. P. et al. (2018) ‘Imaging of Combat-Related Thoracic Trauma - Review of Penetrating Trauma’, Military medicine, 183(3–4), pp. e81–e88. doi: 10.1093/milmed/usx034.
Long, B. (2019) ‘Cardiac Trauma’, in The Emergency Medicine Trauma Handbook. Cambridge University Press, pp. 193–212. doi: 10.1017/9781108647397.015.
Melo, A. S. A. de et al. (2017) ‘Tomographic aspects of penetrating thoracic trauma: injuries from firearms and other weapons’, Radiologia Brasileira, 50(6), pp. 372–377. doi: 10.1590/0100-3984.2016.0167.
Mirvis, S. E. (2004) ‘Diagnostic imaging of acute thoracic injury’, Seminars in Ultrasound, CT and MRI, 25(2), pp. 156–179. doi: 10.1016/j.sult.2004.02.001.
Monteiro Tavares Pereira, B. et al. (2013) ‘Penetrating cardiac trauma: 20-y experience from a university teaching hospital’, Journal of Surgical Research, 183(2), pp. 792–797. doi: 10.1016/j.jss.2013.02.015.
Morse, B. C. et al. (2016) ‘Penetrating cardiac injuries’, Journal of Trauma and Acute Care Surgery, 81(4), pp. 623–631. doi: 10.1097/TA.0000000000001165.
Nicol, A. J. et al. (2015) ‘Screening for occult penetrating cardiac injuries’, Annals of Surgery, 261(3), pp. 573–578. doi: 10.1097/SLA.0000000000000713.
Nummela, M. T. et al. (2019) ‘Imaging of penetrating thoracic trauma in a large Nordic trauma center’, Acta Radiologica Open, 8(12), p. 205846011989548. doi: 10.1177/2058460119895485.
Plurad, D. S. et al. (2013) ‘Penetrating cardiac injury and the significance of chest computed tomography findings’, Emergency Radiology, 20(4), pp. 279–284. doi: 10.1007/s10140-013-1113-0.
Rabinovici, R. (2014) ‘Sixty-seven consecutive resuscitative thoracotomies by a single surgeon’, Scandinavian Journal of Surgery, 103(2), pp. 156–160. doi: 10.1177/1457496914529931.
Raptis, D. A., Bhalla, S. and Raptis, C. A. (2019) ‘Computed Tomographic Imaging of Cardiac Trauma’, Radiologic Clinics of North America, 57(1), pp. 201–212. doi: 10.1016/j.rcl.2018.08.009.
Reddy, D. and Muckart, D. J. J. (2014) ‘Holes in the heart: an atlas of intracardiac injuries following penetrating trauma’, Interactive CardioVascular and Thoracic Surgery, 19(1), pp. 56–63. doi: 10.1093/icvts/ivu077.
Reis, A. L. F. d’Ávila et al. (2012) ‘Janela pericárdica : história e seu uso nos dias atuais’, Rev Med Minas Gerais, 22(Supl 5), pp. 32–34.
Rhee, P. M. et al. (2000) ‘Survival after emergency department thoracotomy: Review of published data from the past 25 years’, Journal of the American College of Surgeons, 190(3), pp. 288–298. doi: 10.1016/S1072-7515(99)00233-1.
Seamon, M. J. et al. (2009) ‘Emergency Department Thoracotomy for Penetrating Injuries of the Heart and Great Vessels: An Appraisal of 283 Consecutive Cases From Two Urban Trauma Centers’, The Journal of Trauma: Injury, Infection, and
Critical Care, 67(6), pp. 1250–1258. doi: 10.1097/TA.0b013e3181c3fef9.
Seamon, M. J. et al. (2015) ‘An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma’, Journal of Trauma and Acute Care Surgery, 79(1), pp. 159–173. doi: 10.1097/TA.0000000000000648.
Shanmuganathan, K. and Matsumoto, J. (2006) ‘Imaging of Penetrating Chest Trauma’, Radiologic Clinics of North America, 44(2), pp. 225–238. doi: 10.1016/j.rcl.2005.10.002.
Söreide, K. and Söreide, J. A. (2006) ‘Axel H. Cappelen, MD (1858-1919): First Suture of a Myocardial Laceration from a Cardiac Stab Wound’, The Journal of Trauma: Injury, Infection, and Critical Care, 60(3), pp. 653–654. doi: 10.1097/01.ta.0000196327.89501.7c.
Stranch, E. W., Zarzaur, B. L. and Savage, S. A. (2017) ‘Thinking outside the box: re-evaluating the approach to penetrating cardiac injuries’, European Journal of Trauma and Emergency Surgery, 43(5), pp. 617–622. doi: 10.1007/s00068-016-0680-7.
Sugiyama, G. et al. (2011) ‘Traumatic ventricular septal defect’, Annals of Thoracic Surgery. Elsevier Inc., 91(3), pp. 908–910. doi: 10.1016/j.athoracsur.2010.08.071.
Suh, W. M. and Kern, M. J. (2009) ‘Transcatheter closure of a traumatic VSD in an adult requiring an ASD occluder device’, Catheterization and Cardiovascular Interventions, 74(7), pp. 1120–1125. doi: 10.1002/ccd.22141.
Thandroyen, F. T. and Matisonn, R. E. (1981) ‘Penetrating thoracic trauma producing cardiac shunts’, Journal of Thoracic and Cardiovascular Surgery. American Association for Thoracic Surgery, 81(4), pp. 569–573. doi: 10.1016/s0022-5223(19)39489-9.
Thorson, C. M. et al. (2012) ‘Does hemopericardium after chest trauma mandate sternotomy?’, Journal of Trauma and Acute Care Surgery, 72(6), pp. 1518–1525. doi: 10.1097/TA.0b013e318254306e.
TOMASELLI, F. et al. (2003) ‘Severe heart laceration in penetrating chest trauma: thoracoscopy as a key to diagnosis’, Interactive Cardiovascular and Thoracic Surgery, 2(3), pp. 270–272. doi: 10.1016/S1569-9293(03)00057-4.
Topal, A. E., Celik, Y. and Eren, M. N. (2010) ‘Predictors of Outcome in Penetrating Cardiac Injuries’, The Journal of Trauma: Injury, Infection, and Critical Care, 69(3), pp. 574–578. doi: 10.1097/TA.0b013e3181bc783a.
Tun, M. et al. (2017) ‘“Mending A Broken Heart!” (a few technical tips on repairing penetrating trauma to the heart)’, Chirurgia, 112(5), p. 619. doi: 10.21614/chirurgia.112.5.619.
Tyburski, J. G. et al. (2000) ‘Factors Affecting Prognosis with Penetrating Wounds of the Heart’, The Journal of Trauma: Injury, Infection, and Critical Care, 48(4), pp. 587–591. doi: 10.1097/00005373-200004000-00002.
Uchimura, M. M. et al. (2010) ‘Epidemiological analysis of pericardiotomys held in a university hospital of Curitiba’, Revista do Colegio Brasileiro de Cirurgioes, 37(2), pp. 92–95. doi: 10.1590/s0100-69912010000200004.
van Waes, O. J. F. et al. (2012) ‘Immediate thoracotomy for penetrating injuries: Ten years’ experience at a Dutch level I trauma center’, European Journal of Trauma and Emergency Surgery, 38(5), pp. 543–551. doi: 10.1007/s00068-012-0198-6.