Late sequelae of penetrating cardiac injuries

Depressed mother penetrating her Baby's heart with a sewing needle during COVID-19 lockdown: A case report

Background

The full lockdown was carried out in China as well as in other countries during the COVID-19 pandemic, and it proved to be effective in reducing the rate of transmission in the early stage of the pandemic. However, the negative effects of full lockdown on human mental health should be taken into consideration.

Case presentation

During COVID-19 lockdown, a 3-month-old male infant was injured with a sewing needle penetrating into his heart by his mother with postpartum depression. The mother had a history of depression, and she reported depressive feelings during quarantine before injuring the infant. In addition, her own mother's health condition had worsened lately following long-term stroke sequelae. These factors may have contributed to her new depressive episode, which caused her to injure her baby with a threaded sewing needle with no witness. The injury was discovered the next day by the infant's paternal grandmother. The baby received an emergency sewing needle removal operation and recovered uneventfully.

Conclusions

Special attention should be paid to persons with a high risk of mental disorder during this pandemic, in order to avoid devastating adverse events or deterioration of conditions for them and those around them.

Traumatic Ventricular Septal Defect After Stab Wound to the Chest Missed by Transthoracic Echocardiography: A Case Report

Traumatic ventral septal defect may be sustained after either blunt force or penetrating trauma to the chest. Severity ranges from asymptomatic to acute decompensated heart failure. Our patient suffered a stab wound to the chest and was initially taken to the operating room for repair of a lacerated right ventricle. Subsequent postoperative hemodynamic deterioration prompted a bedside transthoracic echocardiogram, which failed to identify causal factors. A transesophageal echocardiogram performed immediately after ventral septal defect was demonstrated. This case serves to highlight the gaps in current standard practice and encourages the use of transesophageal echocardiogram as a screening tool in patients after penetrating cardiac injuries.

Cardiac trauma

The first description of a cardiac injury is found in The Iliad. Cardiac injuries are one of the most challenging injuries, requiring immediate surgical intervention, excellent surgical skills and critical care. The clinical presentation of penetrating cardiac injuries has a broad range, from haemodynamic stability to cardio-pulmonary arrest. Two-dimensional echocardiography is now the procedure of choice over subxiphoid pericardial window to evaluate for the presence of these injuries. Emergency department thoracotomy is indicated for management of penetrating cardiac injuries with immediate cardiography, aortic cross-clamping and open cardiac massage. The left anterolateral thoracotomy is the incision of choice for patients that arrive in extremis. The repair of the wounds should be performed according to the anatomy of the injured area. Mortality remains high, although better patient selection according to physiologic scoring leads to increase in survival.

Cardiac trauma during teenage years

The spectrum of blunt cardiac trauma ranges from asymptomatic myocardial contusion to fatal cardiac arrhythmias and/or cardiac rupture. Although cardiac rupture is common in fatal traffic accidents, these patients rarely reach hospital care. Insignificant blunt cardiac injury during sports may cause fatal arrhythmia in teens. Penetrating cardiac trauma is fairly common in the United States, encountered frequently in major urban centers. Most cases are dead at the scene and never reach hospital. The incidence of cardiac sequelae in survivors is high, and these patients should be evaluated with early and late echocardiography to detect anatomic or functional cardiac involvement.

Relationship of echocardiographic and coronary angiographic findings in patients with acute myocardial infarction secondary to penetrating cardiac trauma

BACKGROUND

Patients with cardiac wounds could experience a posttraumatic acute myocardial infarction (PAMI) as a complication. Usually, this complication is explained by occlusion of a coronary artery, but sometimes, it cannot be explained by this pathophysiologic finding. This study aimed to determine the incidence of PAMI, make an approximation of PAMI pathophysiology, and propose management strategies.

METHODS

A prospective observational study was conducted at San Vicente de Paul University Hospital in Medellin, Colombia. During 12 months, we studied 51 patients with a history of a cardiac stab injury. We evaluated variables, such as Revised Trauma Score (RTS), surgical and anesthetic data, and possible risk factors. Diagnosis of PAMI was based on electrocardiogram, echocardiography, and troponin I serum levels. All PAMI patients had an coronary angiography. Risk factors possibly related to the development of PAMI were explored.

RESULTS

Fifty-one patients were evaluated; three died (5.9%). Of the patients, 35 (68.62%) did not develop PAMI, 6 (11.76%) developed PAMI with coronary injury, and 10 (19.6%) experienced PAMI without coronary injury (PAMIWCI). An RTS of 5.3 or lower and a Glasgow Coma Scale score of 9 or lower were risk factors associated with PAMIWCI (relative risk, 11.55; p = 0.03). We did not find a relationship between PAMI and the use of psychoactive substances or other comorbidities.

CONCLUSION

Patients with penetrating cardiac trauma may develop PAMIWCI. Active search for PAMI must be done in all patients with cardiac stab wound trauma, even those without artery coronary injury or symptoms suggestive of coronary ischemia. It is likely that Glasgow Coma Scale score of 9 of lower and RTS of 5.3 of lower for patients with cardiac injury are associated with the development of PAMIWCI.

Thoracic trauma: when and how to intervene

Trauma is the leading cause of death in patients younger than 40 years of age. Thoracic injuries are common and often can be managed by tube thoracostomy. In many patients, however, the thoracic injuries must be repaired surgically in one of three time periods: immediate, urgent, or delayed thoracotomy. In this article, we describe the general approach to effectively managing thoracic trauma patients. We review common injuries and scenarios that may be encountered by the surgeon and discuss the considerations and variables that enter into the decision-making process for operative intervention.

[Cardiac sequelae of penetrating cardiac wounds]

OBJECTIVE

The aim of our work was to study cardiac sequelae of penetrating cardiac injuries.

MATERIAL AND METHODS

It is a retrospective study including nine patients (eight men and one woman with an average age of 26.6 +/- 7.4 years) hospitalised between January 1st, 1988 and December 31, 2002 in cardiovascular surgery department of Tunis Rabta hospital for heart wounds.

RESULTS

It was stab wounds in all patients. Heart lesions concerned primarily the right ventricle. In admission, two patients had cardiac tamponade and seven were in shock. Beating heart surgery without cardiopulmonary bypass in all patients performed surgical repair and it consisted in simple suture. Functional symptoms were observed in five patients at late outcome. Five patients had heart sequelae. It consisted of conduction abnormalities (right bundle branch block) in five patients. One patient had a small ventricular septal defect. Finally, partial permanent disability rates were less than 10%.

CONCLUSION

Cardiac sequelae of penetrating cardiac wounds have good prognosis with the exception of a small partial permanent disability rate. Their prevention must be based on the fight against the urban violence and on the good initial management.

Penetrating Cardiac Injuries: Recent Experience in South Africa

BACKGROUND

Penetrating cardiac injury is a dramatic and lethal form of trauma. The majority of patients will die before reaching medical care, but for those who arrive at hospital alive, the diagnostic acumen and rapid surgical intervention of physicians and surgeons can lead to successful outcomes.

MATERIALS AND METHODS

A structured diagnostic and management approach is used in our trauma unit to deal with penetrating cardiac injury. A retrospective study of 117 patients with penetrating trauma to the heart was conducted over 32 months; the purpose of this study was to describe our protocol and review overall outcome with this type of injury. Demographic details, mechanism of injury, and mode of presentation were recorded. Mortality and morbidity data were collated and echocardiographic follow-up was performed.

RESULTS

There were 109 male patients, mean age 29 years (range: 15-54 years) and 8 female patients, mean age 35 years (range: 23-56 years). Most patients (96/117) had sustained stab wounds, and the associated mortality was 15.6%. Twenty-one patients had sustained gunshot wounds (GSW), with a mortality of 81%. Gunshot wounds were significantly more likely to result in death (P<or=0.0001). Five patients sustained multiple cardiac wounds, and three of them died. The risk of death was not different between patients sustaining single or multiple cardiac wounds (P=0.11). Eleven patients had thoracoabdominal injury, and 3/11 (27%) died; all of those that died had sustained GSW. The risk of death was not different between patients sustaining thoracoabdominal wounds and those with isolated thoracic injury (P=1.0). Among the 51 patients with stab wounds who presented with cardiac tamponade, the mortality was only 8%. Compared to the other patients with stab wounds, cardiac tamponade conferred a significant survival advantage (P=0.02).

CONCLUSIONS

A high index of suspicion for penetrating cardiac injury and an understanding of the modes of presentation can lead to rapid diagnosis even by inexperienced junior staff. Such a structured approach to patients with penetrating trauma to the chest leads to early definitive management and acceptable results.

Delayed presentation of left ventricular outflow tract aneurysm after penetrating cardiac trauma

We report a case of posttraumatic left ventricular outflow tract aneurysm in a patient who had a stab injury to the chest requiring emergency operation 40 years previously. After apparent decades without symptoms, the patient presented with exertional dyspnea. Clinical and echocardiographic assessment revealed aortic regurgitation and left ventricular outflow tract aneurysm. Injuries to the chest wall that penetrate the heart and great vessels are life-threatening and require emergency operative intervention. However, these injuries rarely, as in this case, result in chronic cardiac aneurysm and aortic valvular incompetence.

Trauma to cardiac valves

Cardiorrhaphy is a relatively common procedure performed in a trauma center. However, there is a subgroup of patients with more complicated cardiac injuries such as coronary artery injuries, septal defects, and valvular injuries. Cardiac valvular injuries are often diagnosed subacutely when a new murmur is heard. Transesophageal echocardiography has been increasingly performed to diagnosis these injuries and may be helpful intraoperatively. Cardiac catheterization may be indicated in selected patients. Techniques to address these injuries may involve repair or prosthetic replacement. A high index of suspicion is needed to diagnose these relatively rare injuries.

Mediastinal trauma

The evaluation of mediastinal trauma has undergone some important changes in the last few years. Electrocardiography (ECG) combined with troponin measurements have become the standard of evaluation of suspected blunt cardiac trauma. Spiral computerized tomography (CT) scan has largely replaced angiography for suspected blunt aortic rupture. There is good evidence that with a suspicious mechanism of injury the thoracic aorta should be evaluated irrespective of chest X-ray findings.

In penetrating trauma the introduction of trauma ultrasound in the emergency room has revolutionized the early diagnosis of cardiac tamponade. Most mediastinal gunshot wounds in haemodynamically stable patients can safely be managed non-operatively. Evaluation of the direction of the bullet tract by means of spiral CT scan has replaced angiography and oesophageal studies in about 75% of patients with mediastinal gunshot wounds who are haemodynamically stable.

Natural history of a ventriculoatrial fistula after a gunshot injury in 1945

We describe an exceptional case of a patient who suffered a penetrating heart injury from a gunshot wound in 1945 leading to a left ventricular-right atrial fistula. Despite the resulting left-to-right shunt the patient remained relatively asymptomatic for 50 years before the onset of congestive heart failure necessitated an operation.

Delayed traumatic aorto-pulmonary artery fistula

Delayed aorto-pulmonary artery fistula represents an uncommon delayed sequelae of penetrating cardiac trauma. A case is presented that demonstrates the need for a high index of suspicion, follow-up, and a complete evaluation of the patient who survives a penetrating heart injury. The mechanisms of delayed presentation, diagnosis, and management of the fistula are discussed.

Acute management of complex cardiac injuries

BACKGROUND

Injury to the heart has been studied extensively. However, a small group of patients with injuries to the coronary arteries or intracardiac structures may require a different operative approach.

METHODS

Retrospective review of a cardiovascular injury database.

RESULTS

Over a 20-year period, 711 cardiac injuries were treated. The mean age of the victims was 31.1 (90% men). Causes were primarily stab wounds (54%) and gunshot wounds (42%). Cardiac chambers injured included the right ventricle (40%), left ventricle (40%), right atrium (24%), and left atrium (3%). The overall mortality was 47%. Sixty complex injuries occurred. Of 21 left anterior descending coronary artery injuries (76.2% mortality), two patients presented with sufficient signs of life to warrant emergent coronary artery bypass (mortality 50%). There were seven circumflex/obtuse marginal coronary artery injuries, all treated with ligation (mortality 71.4%). Eight right/posterior descending coronary artery injuries (mortality 62.5%) were seen, and all but one were treated with ligation. The one patient not treated with ligation underwent coronary bypass and died. Delayed mitral valve replacement was performed for two valvular injuries (mitral). There were a total of 14 intracardiac fistulas (mortality 35.7%). All six of the surviving patients with ventricular septal defect required reoperation.

CONCLUSION

The mortality for complex injuries (coronary, septal, valvular) was 53%. This group was a specific population that self-selected by surviving to operation. Acute operations for complex injuries (beyond cardiorrhaphy) were primarily heroic life-saving efforts. Reoperation for cardiac injuries was most common for septal or valvular injuries. Only 2% of all survivors required reoperation to correct a residual defect.

Penetrating cardiac injuries

Penetrating cardiac injuries pose a tremendous challenge to any trauma surgeon. Time, sound judgment, aggressive intervention, and surgical technique are the most important factors contributing to positive outcomes. This article extensively reviews the history, surgical management, and techniques needed to deal with these critical injuries. This year commemorates the one hundredth anniversary of the first successful repair of a cardiac injury.

Factors influencing outcome in stab wounds of the heart

BACKGROUND

The purpose of this study was to identify factors associated with unfavorable outcome following stab wounds to the heart in order to improve selection of patients who may benefit from aggressive resuscitative efforts.

METHODS

Preoperative and operative variables were reviewed for all patients treated for cardiac stab wounds at a level I trauma center from 1987 to 1993 in an attempt to identify factors influencing survival.

RESULTS

Twenty-nine (53%) of the 55 patients who were resuscitated following stab wounds to the heart during the study period survived. Although profound hypotension (systolic blood pressure < 40 mm Hg), cardiopulmonary resuscitation, and emergency room thoracotomies were associated with poor outcome, none were uniformly predictive of death. Some patients survived with each of these characteristics.

CONCLUSIONS

We recommend that all patients suspected of having cardiac stab wounds be fully resuscitated and undergo thoracotomy, as significant survival can be achieved and death is not always the outcome.

Surgical correction of posttraumatic VSD via the right atrium

We report the cases of four patients seen with ventricular septal defects (VSDs) resulting from penetrating chest trauma; initial surgical management was via left thoracotomy and comprised relief of tamponade and suture of the surface cardiac wound. A VSD was suspected in all four patients postoperatively on the basis of a holosystolic murmur as confirmed with two-dimensional echo and angiography. Elective surgical repair was undertaken on cardiopulmonary bypass with bicaval cannulation and cardioplegic arrest. The interventricular septum was approached through the right atrium (no attempt was made to free the anterior surface of the right ventricle from adhesions). Three defects were closed directly and one was closed with a pericardial patch. The surgical correction of posttraumatic VSD from a penetrating injury can be safely and effectively achieved via a right atrial approach.