Acute management of complex cardiac injuries

Damage control thoracic surgery: What you need to know

ABSTRACT

Damage control surgery in trauma prioritizes patient stabilization through an initial temporizing surgical approach to rapidly control hemorrhage and contamination, minimizing intraoperative time to allow for resuscitation and the correction of hypothermia, coagulopathy, and acidosis in the intensive care unit. This is followed by definitive repair of injuries once physiological parameters have improved. While damage control techniques for traumatic intra-abdominal and extremity injuries are well established and frequently utilized, the same cannot be said for damage control thoracic surgery. The complexity of thoracic injuries, the intricate decision making process, the level of surgical expertise required, and potential complications make damage control thoracic surgery particularly challenging. However, advances in surgical techniques, improvements in perioperative care, and the emergence of adjuncts such as extracorporeal membrane oxygenation have significantly enhanced decision making and underscored the importance of timely and decisive intervention in damage control thoracic surgery to optimize patient outcomes. This review aims to provide a comprehensive overview of damage control thoracic surgery, detailing the principles, indications, operative techniques, perioperative management, and the integration of advanced therapies to improve outcomes in patients with severe thoracic injuries.

Diagnosis and management of blunt cardiac injury: What you need to know

ABSTRACT

Blunt cardiac injury (BCI) encompasses a wide spectrum, from occult and inconsequential contusion to rapidly fatal cardiac rupture. A small percentage of patients present with abnormal electrocardiogram or shock, but most are initially asymptomatic. The potential for sudden dysrhythmia or cardiac pump failure mandates consideration of the presence of BCI, including appropriate monitoring and management. In this review, we will present what you need to know to diagnose and manage BCI.

Spontaneous coronary artery rupture after lung cancer surgery: A case report and review of literature

BACKGROUND

Spontaneous coronary artery rupture (SCAR) is a rare and life-threatening complication after lung cancer surgery. We present a case of SCAR following left upper lobectomy, successfully managed through emergency thoracotomy and coronary artery ligation.

CASE SUMMARY

A 61-year-old male patient underwent left upper lobectomy and mediastinal lymph node dissection for lung cancer. The surgery was performed using single-port video-assisted thoracoscopic surgery, and there were no observed complications during the procedure. However, 19 h after surgery, the patient experienced chest discomfort and subsequently developed severe symptoms, including nausea, vomiting, and a drop in blood pressure. Urgent measures were taken, leading to the diagnosis of SCAR. The patient underwent emergency thoracotomy and coronary artery ligation, successfully stopping the bleeding and stabilizing the condition. Despite postoperative complications, the patient made a successful recovery and was discharged from the hospital.

CONCLUSION

SCAR is a rare but life-threatening complication following lung cancer surgery. Immediate thoracotomy has been shown to be a life-saving measure, while stenting is not the preferred initial approach.

A Knife Penetrating the Right Ventricle, Interventricular Septum, and 2 Valves: A Case Report

Penetrating chest trauma may result in significant intracardiac injury. A traumatic ventricular septal defect is a rare complication that requires surgical management, particularly if heart failure ensues. We report a case of delayed repair of an outlet-type ventricular septal defect and perforation of the aortic and pulmonary valve leaflets following a stab wound. This report highlights diagnostic and surgical considerations and also presents an opportunity to review the conotruncal anatomy, which may be relatively unfamiliar to many adult cardiac surgeons.

Penetrating right ventricular injury following a single gunshot to the left flank in Iraq: a case report

A century ago, cardiac injuries usually resulted in death. However, despite all the advances in medicine, these injuries still have high mortality and morbidity rates. In the present case, we describe a patient with a bullet injury to the right ventricle who survived at our hospital despite the limitations of our center with regard to modalities and equipment. A 30-year-old man was brought to our emergency department with a bullet wound to his left flank. He was hemodynamically unstable. After only 8 minutes in the hospital and without further investigations he was rushed to the operating room. During laparotomy, a clot was visible in the left diaphragm, which dislodged and caused extensive bleeding. The decision was made to perform a sternotomy in the absence of a sternal saw. An oblique 8-cm injury to the right ventricle was discovered following rapid exploration. It was repaired without the need for cardiopulmonary bypass surgery. After a few days in the hospital, the patient was discharged home. In the event of a penetrating cardiac injury, rapid decision-making is crucial for survival. Whenever possible, the patient should be transferred to the operating room, as emergency department thoracotomies are associated with a high mortality rate.

Retrospective analysis of 261 autopsies of penetrating cardiac injuries with emphasis on sociodemographic factors

Penetrating cardiac injuries (PCIs) are highly lethal and several factors are related to its incidence and mortality. While most studies focus on characterizing patients who arrived at a medical facility alive and exploring the relationship between the degree of heart compromise and mortality, our study delved deeper into the topic. This study analyzed 261 autopsy reports from 2017 in Bogotá, Colombia, and characterized the factors surrounding PCI incidence and mortality while emphasizing the role of sociodemographic variables. Of these cases, 247 (94.6%) were males with a mean age of 29.19 ± 9.7 years. Weekends, holidays, and late hours had the highest incidence of PCIs. The victims' deaths occurred at the scene in 66 (25.3%) cases, and 65.1% of the victims died before receiving medical care. Upon admission, patients with vital signs were more likely to have been transported by taxi or a private vehicle. Two or more compromised cardiac chambers, increased time of transportation, trauma occurred in the city outskirts, and gunshot wounds were related to increased mortality. Our data is valuable for surgeons, health system managers, and policy analysts as we conducted a holistic assessment of the anatomical and sociodemographic factors that are closely associated with mortality following a PCI. Surgeons must recognize that PCIs can occur even when the entrance wound is outside the cardiac box. Reinforcing hospital infrastructure in the outskirts and improving the availability, accuracy, and response time of first responders may lead to improved patient mortality rates.

Nationwide utilization of cardiopulmonary bypass in cardiothoracic trauma: A retrospective analysis of the National Trauma Data Bank

BACKGROUND

The American College of Surgeons Committee on Trauma requires that all level I trauma centers have cardiopulmonary bypass (CPB) capabilities immediately available. Despite this mandate, there are limited data on the utilization and clinical outcomes among trauma patients requiring CPB in the management of injuries. The aim of this study was to evaluate the current use of CPB in the care of trauma patients.

METHODS

This is a retrospective analysis of the National Trauma Data Bank from 2010 to 2015. Adult patients sustaining cardiothoracic injuries who underwent surgical repair within the first 24 hours of admission were included. Propensity score matching was used to compare outcomes (in-hospital mortality, hospital length of stay (LOS), intensive care unit LOS, and complications) between patients who underwent CPB within the first 24 hours of admission and those with similar injuries who did not receive CPB.

RESULTS

A total of 28,481 patients who met the inclusion criteria were identified, of whom 319 underwent CPB. Three-hundred three CPB patients were matched to 895 comparison patients who did not undergo CPB. Overall in-hospital mortality was 35%. Patients who were not treated with CPB had a significantly higher in-hospital mortality compared with those treated with CBP (odds ratio, 1.57; 95% confidence interval, 1.16-2.12; p = 0.003); however, complications were significantly lower in those who did not receive CPB (odds ratio, 0.63; 95% confidence interval, 0.47-0.86; p = 0.003). Hospital LOS (non-CPB: mean, 13.4 ± 16.3 days; CPB: mean, 14.7 ± 15.1 days; p = 0.23) and intensive care unit LOS (non-CPB: mean, 9.9 ± 10.7 days; CPB: mean, 10.1 ± 9.7 days; p = 0.08) did not differ significantly between groups.

CONCLUSION

The use of CPB in the initial management of select cardiothoracic injuries is associated with a survival benefit. Further investigation is required to delineate which specific injuries would benefit the most from the use of CPB.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Damage control in penetrating cardiac trauma

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

Use of the EVARREST patch for penetrating cardiac injury

Penetrating cardiac injuries have a pre-hospital mortality of 94% with a subsequent in-hospital mortality of 50% among initial survivors (Leite et al., 2017 [1]). The Western Trauma Association (WTA) guidelines recommend resuscitative thoracotomy (RT) for patients with penetrating torso trauma and less than 15 min of cardiopulmonary resuscitation (CPR) Burlew et al. (2012) [2]. Penetrating cardiac injuries are classically repaired using skin-stapling devices and/or suture repair with or without pledgets (Wall et al., 1997 [3]). In this study, we present a case of penetrating cardiac injury where all the aforementioned techniques failed, and a new approach was explored. A fibrinogen/thrombin patch was used in this clinical setting, which is an off-label use of the product, we here present our encouraging outcome.

Delayed presentation of cardiac injury four weeks after stabbing

Penetrating trauma to the heart has a high associated mortality due to significant hemorrhage, coronary artery injury, and cardiac tamponade. Such sequelae progress rapidly, often leading to death before reaching hospital. We report a case of delayed presentation following a stab injury to the right ventricle. This case highlights the mechanisms that may facilitate a delayed presentation and the importance of appropriate investigation when suspicion of cardiac injury is high.

Traumatic cardiac injury: Experience from a level-1 trauma centre

PURPOSE

Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short thera- peutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI.

METHODS

Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15.

RESULTS

Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio be- tween blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p =0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%.

CONCLUSION

High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

Coronary artery rupture in blunt thoracic trauma: a case report and review of literature

BACKGROUND

Blunt thoracic trauma can rarely result in coronary artery injury. Blunt trauma can result in occlusion of any of the coronary arteries or can lead to its rupture and bleeding. Traumatic coronary artery occlusion can lead to myocardial infarction, while its rupture and bleeding can result in hemopericardium and cardiac tamponade, and can be rapidly fatal. Survival after coronary artery rupture in blunt thoracic trauma is exceedingly rare.

CASE PRESENTATION

We present a case of a young male who sustained a blunt thoracic trauma in a motor vehicle collision, that resulted in rupture of the left anterior descending (LAD) coronary artery and subsequent cardiac tamponade. Prompt surgical intervention with pericardiotomy and ligation of the artery has resulted in survival of the patient.

CONCLUSIONS

In cases of traumatic coronary artery rupture, early surgical intervention is crucial to avoid mortality. Ligation of the injured coronary is a viable option in selected cases, and can be the most expeditious option in patients in extremis.

Predictors of Positive Subxiphoid Pericardial Window in Stable Patients with Penetrating Injuries to the Precordial Region

BACKGROUND

Subxiphoid pericardial window (SPW) remains a valuable diagnostic tool for patients at risk of occult cardiac injuries. However, how to select patients that could benefit from this procedure remains unclear. We aimed to identify clinical predictors of positive SPW in patients with penetrating precordial injuries.

MATERIALS AND METHODS

Prospective data collection of 183 patients who underwent SPW for the exclusion of penetrating cardiac injuries during 2002 - 2004 at a level I trauma centre in Cali, Colombia. Patient's demographics, clinical characteristics, and injury information were obtained. Independent predictors of positive SPW were assessed using stepwise logistic regressions.

RESULTS

There were 41 positive SPW (22.4%). Unadjusted analyses demonstrated that stab/knife wounds (OR 2.48, 95% CI 1.17-5.25, p = 0.017), single wound (OR 14.61, 95% CI 1.9-110, p = 0.009), and clinical signs of pericardiac tamponade (OR 8.52, 95% CI 3.92-18.4, p < 0.001) were associated with increased odds of positive SPW. Conversely, systolic blood pressure (0.98, 95% CI 0.96-0.99) and stable physiological index (OR 0.31, 95% CI 0.14-0.65, p = 0.002) were associated with decreased odds. In multivariable analyses, signs of pericardiac tamponade (OR 6.37, 95% CI 2.78-14.6, p < 0.001), and single injuries (OR 12.99, 95% CI 1.6-102.7, p = 0.015) remained as independent predictors of positive SPW.

CONCLUSION

Emphasis on early recognition of the clinical signs of pericardiac tamponade could be the most important factor for the identification of occult cardiac injuries. Patients with multiple wounds to the precordial region who reached the hospital may not benefit from a SPW. However, high level of awareness is important because the incidence of occult cardiac injuries is not negligible.

Delayed revascularization following complete transection of left anterior descending artery after a stab wound

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Complete coronary artery transection after a stab wound is survivable.

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At even slight suspicion, surgical exploration of pericardial sac and heart is always strongly justified.

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Off-pump coronary artery by-pass is a safe alternative for transected artery treatment.

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Examination and treatment of cardiac injuries in facility with “heart team” and cardiac surgical expertise is always strongly recommended.

Introduction

Penetrating heart injury as a consequence of a stab wound is usually considered fatal. Nevertheless, there are rare lucky cases with mild symptoms which deserve clinical suspicion and proper management.

Presentation of case

We report a penetrating cardiac trauma with left anterior descending coronary artery transection after a stab wound. Successful revascularization without cardiopulmonary bypass support was performed.

Discussion

Coronary artery injuries after penetrating cardiac trauma are mostly fatal. The standard approach has traditionally been coronary artery ligation with serious morbidity. We report a case of complete coronary artery transection with delayed revascularization validating the safety of off-pump approach. We add a short literature review of the management of traumatic coronary artery injury.

Conclusion

This adds to the world literature on coronary artery trauma with successful off-pump revascularization. Coronary artery transection stab-wound victims can have only mild symptoms. Slightest intimation of heart injury should provoke proper clinical examination and management.

Western Trauma Association critical decisions in trauma: resuscitative thoracotomy

BACKGROUND

In the past three decades, there has been a significant clinical shift in the performance of resuscitative thoracotomy (RT), from a nearly obligatory procedure before declaring any trauma patient deceased to a more selective application of RT. We have sought to formulate an evidence-based guideline for the current indications for RT after injury in the patient.

METHODS

The Western Trauma Association Critical Decisions Committee queried the literature for studies defining the appropriate role of RT in the trauma patient. When good data were not available, the Committee relied on expert opinion.

RESULTS

There are no published PRCT and it is not likely that there will be; recommendations are based on published prospective observational and retrospective studies, as well as expert opinion of Western Trauma Association members. Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be stratified based on injury and transport time. Indications for RT include the following: blunt trauma patients with less than 10 minutes of prehospital CPR, penetrating torso trauma patients with less than 15 minutes of CPR, patients with penetrating trauma to the neck or extremity with less than 5 minutes of prehospital CPR, and patients in profound refractory shock. After RT, the patient's intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead. Patients with a cardiac wound, tamponade, and associated asystole are aggressively treated. Patients with an intrinsic rhythm following RT should be treated according to underlying primary pathology. Following several minutes of such treatment as well as generalized resuscitation, salvageability is reassessed; we define this as the patient's ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary.

CONCLUSION

The success of RT approximates 35% for the patient arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds. Conversely, patient outcome is relatively poor when RT is performed for blunt trauma, 2% survival for patients in shock and less than 1% survival for patients with no vital signs. Patients undergoing CPR on arrival to the hospital should be stratified based on injury and transport time to determine the utility of RT. This algorithm represents a rational approach that could be followed at trauma centers with the appropriate resources; it may not be applicable at all hospitals caring for the injured. There will be patient, personnel, institutional, and situational factors that may warrant deviation from the recommended guideline. The annotated algorithm is intended to serve as a quick bedside reference for clinicians.

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.

Incidence of postoperative acute renal failure among violence-related cardiovascular trauma patients: a review of our experience in 117 cases

BACKGROUND

The purpose of this retrospective study was to determine the incidence of renal failure and hemodialysis (HD) in postoperative period after cardiovascular surgery associated with trauma.

METHODS

One hundred and seventeen cases of violence-related cardiovascular trauma patients had emergent surgery between 1996 and 2009. Cases were reviewed in three main groups: Cardiac trauma in 11 patients (Group A), vascular trauma in 78 patients (Group B), and cardiovascular trauma in 28 patients (Group C). Postoperative incidence of HD requirements with acute renal failure (ARF) was investigated in these groups of patients postoperatively.

RESULTS

Multiorgan deficiency developed in 10 patients from Group A, in 45 patients from Group B, and in 26 patients from Group C. Overall mortality was 81 cases in 117 patients. Total hospitalization periods were 21 +/- 2, 17 +/- 3, and 27 +/- 1 days for Group A, Group B, and Group C, respectively. HD administrations were indicated in 3 patients in Group A, 41 patients in Group B, and 9 patients in Group C. No statistically significant difference presented in any study parameter between groups.

CONCLUSIONS

Cardiovascular trauma is a common reason for emergent cardiovascular surgery. Postoperative renal failure occurs among these patients in a wide percentage. We strongly advocate a close and detailed follow-up of renal functions in these patients during the hospitalization period and immediate HD at indication.

Challenges in the diagnosis of blunt cardiac injuries

INTRODUCTION

Blunt thoracic injuries (BTIs) are directly responsible for 20-25% of all deaths, worldwide. Involvement of heart in BTIs is largely underestimated and ignored, but reasonable estimate would be around 15%. This study was planned to emphasize on clinical-presentation and diagnosis of blunt cardiac injuries (BCIs).

RESULTS

Clinical presentation of BCIs, varied from mild chest discomfort to haemodynamic shock secondary to rapid exsanguinations. Non-specific presentation with associated injuries diverts physician's attention and delayed appearance of clinical features makes diagnosis further difficult. Cardiac markers and ECG are not specific, but high sensitivity of 100% could be reached using combination of elevated cardiactroponin levels and alterations in ECG. Transoesophageal or transthoracic echocardiography, angiography, intravascular ultrasound and nuclear scan have proven to detect cardiac injuries in BTIs, but lack specificity.

CONCLUSION

Patients with suspicious-ECG finding need cardiac-monitoring for at least 24 hours. Haemodynamically stable young (<55 years) subjects, without underlying cardiac diseases and with normal-ECG and cardiac marker, could be discharged safely.

Management of Traumatic Coronary Artery Injuries: Advantages of Off-Pump Coronary Artery Bypass

Coronary artery injuries are rare but highly lethal. Debate exists as to the best treatment for this complex set of injuries, with historical treatment favoring arterial ligation. Although conventional coronary artery bypass grafting using cardiopulmonary bypass has been used somewhat successfully, enthusiasm for off-pump CABG (OPCAB) has grown more recently. We report two unique cases of left anterior descending coronary arterial injuries managed successfully with OPCAB.

Penetrating cardiac injury: overcoming the limits set by Nature

Repair of cardiac wounds was considered impossible little over 100 years ago. Despite progress, penetrating cardiac injury remains a highly lethal form of trauma today. Cardiac tamponade and exsanguination are the greatest immediate and life-threatening risks. Clinical presentation is extremely variable and diagnosis may be highly deceptive. Unlike other forms of trauma, resuscitation is of limited value and urgent operative intervention is the only meaningful treatment. Refinements in cardiothoracic surgery and the simultaneous evolution of trauma care systems have both contributed to saving lives. However, mortality rates for this condition have changed little in the last century, due largely to the rising proportion of more lethal injuries caused by gunshot wounds.

Traumatic ventricular septal defect following a stab wound to the chest

A 51-year-old man who had been suffering from depression stabbed himself in the chest with an ice pick. At presentation, an ice pick lodged in the left fifth intercostal space was moving synchronously with his heartbeat. Echocardiography revealed that the tip was penetrating the anterior wall of the right ventricle. Because the patient was tamponading, an emergency operation was carried out. The ice pick was removed following the establishment of a cardiopulmonary bypass and pericardiotomy. The perforation of the right ventricle was closed with a pledget-reinforced mattress stitch. On postoperative day 12, a holosystolic murmur was detected on auscultation. Transthoracic echocardiography revealed a ventricular septal defect 5 mm in diameter located near the apex. The pulmonary-tosystemic flow ratio was 1.1 by echocardiographic measurement. No sign of heart failure was present. Although it was agreed to manage the ventricular septal defect conservatively, careful echocardiographic follow-up is mandatory.

Prehospital ultrasound detects pericardial tamponade in a pregnant victim of stabbing assault

The development of handheld, portable ultrasound devices has enabled the use of this diagnostic tool also in the out-of-hospital environment. We report on a pregnant teenager who was found haemodynamically unstable after a stab assault. When she suffered cardiac arrest shortly thereafter, diagnosis of cardiac tamponade was made by portable ultrasound, and immediate pericardiocentesis was performed by the emergency physician. While her baby died after emergency Caesarean section, the teenager survived after thoracotomy and prolonged resuscitation without neurological sequelae.

A Concealed Penetrating Cardiac Injury

We present the case of a 29-year-old man who had been the victim of a stab wound. The cardiac wound was localized in the left ventricular apex and the posterior side of the left ventricle. When he was brought to the emergency department, he had no significant symptoms related to the cardiac wound regardless of ECG changes in the V(2)-V(4) precordial derivation. The aim of this case report is to demonstrate the importance of an accurate preoperative diagnosis and urgent surgical intervention to ensure a good outcome in this type of rare case.

Off-Pump Coronary Artery Bypass is an Alternative to Conventional Cardiopulmonary Bypass When Repair of Traumatic Coronary Artery Injuries is Indicated

Coronary artery injuries after penetrating cardiac trauma are rare. The standard approach to these injuries has traditionally been coronary artery ligation. When cardiac perfusion is profoundly compromised, cardiopulmonary bypass has been used to facilitate revascularization, although with serious morbidity. We report a case of traumatic left anterior descending coronary artery transection repaired off-pump in a young stabbing victim. Penetrating traumatic cardiac injuries are highly lethal injuries. Cardiopulmonary bypass has been used for myocardial revascularization when cardiac perfusion is compromised, although with significant complications. Off-pump coronary artery bypass is a safe alternative in the traumatized patient.

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.

Aortic foreign body (airgun pellet) embolism in a cat

A five-year-old female domestic shorthair cat presented with clinical signs typical of an aortic saddle thromboembolism. An echocardiogram and thoracic radiographs excluded cardiac disease as a source of the thrombus. Two heavy metal opacity, pellet-like objects were seen in the thoracic and abdominal radiographs. Abdominal ultrasound demonstrated occlusion of aortic blood flow by the abdominal pellet but could not indicate whether this was due to a penetrating aortic wound or pellet embolisation. A necropsy confirmed a penetrating left ventricular cardiac wound with subsequent embolisation of the pellet to the abdominal aorta.

Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes

In the past three decades there has been a significant clinical shift in the performance of emergency department thoracotomy (EDT), from a nearly obligatory procedure before declaring any trauma patient to select patients undergoing EDT. The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure. Overall analysis of the available literature indicates that the success of EDT approximates 35% in the patient arriving in shock with a penetrating cardiac wound, and 15% for all penetrating wounds. Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. The optimal application of EDT requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences.

Large Left Ventricular Pseudoaneurysm Presenting 25 Years After Penetrating Chest Trauma

Penetrating chest wounds leading to damage of thoracic structures are common. A rare sequelae of chest trauma is a contained rupture of the left ventricle of the heart leading to the development of a pseudoaneurysm. This complication needs prompt recognition and repair because of the high likelihood of rupture and death. We report the case of a 47-year-old man who underwent repair of a stab wound to the heart 25 years ago and subsequently developed a large left ventricular pseudoaneurysm and presented with angina.

Selective penetrating injury of the right coronary artery: a fatal case

Penetrating chest trauma leading to selective coronary artery injury is uncommon. Their incidence is not accurately established because the clinical diagnosis is difficult and the lesion is often revealed only during autopsy. The mortality rate remains high. We report a fatal case of selective right coronary artery injury due to a penetrating wound directed to the right chest.

Damage control surgery for thoracic injuries

Damage control of thoracic injuries begins frequently with an emergency department thoracotomy via an anterolateral incision. Bleeding and air leaks are quickly temporised. As opposed to abdominal damage control where most injuries can be temporised, most thoracic injuries require initial definitive repair. Thus, the goal of thoracic damage control is to perform the least definitive repair using the fastest and easiest techniques to shorten the operative time as much as possible. There are some injuries that can be temporised and require re-operation once physiologic normality has been achieved.

Off-pump cardiac revascularization after a complex stab wound

Penetrating cardiac injuries are among the most dramatic and lethal of all injuries. High survival rates in selected reports have given the erroneous impression that the lethality of cardiac injuries has diminished in recent years. In a review of 1,198 cases of penetrating cardiac trauma from South Africa, only 6% of patients arrived at hospital alive. Many patients with proximal coronary artery injuries present without signs of life. Cardiopulmonary bypass is advocated as a means of salvage, but mortality rates are high. We present a case of arterial revascularization using off-pump technology.

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.

The use of off pump surgery for management of penetrating coronary artery injury

Penetrating trauma to the chest leading to coronary artery injury is associated with a high mortality rate, especially in the case of injury to the left anterior descending (LAD) coronary artery. The mortality rate remains high whether they are managed with primary ligation or with coronary artery bypass grafting using conventional cardiopulmonary bypass techniques. We report a case of proximal LAD coronary artery injury successfully treated with off pump coronary revascularisation.

The management of stab wounds to the heart with laceration of the left anterior descending coronary artery

Penetrating cardiac injuries are an increasing cause of traumatic deaths in urban areas. The management of these injuries has undergone a transition from simple pericardiocentesis to cardiac ultrasound evaluation in the stable patient, and emergency thoracotomy and repair of myocardial wounds in the unstable patient in extremes. The incidence of traumatic coronary artery injury is not accurately known because not all victims are examined. With the improvement in emergency medical services, including speed of transportation of these patients, better resuscitation, and knowledgeable use of cardiac ultrasound or emergency room thoracotomy, more patients with coronary artery injuries will survive and reach the operating room. The operative management of the injured coronary artery is dependant on the location of the injury and whether there is myocardial dysfunction. Distal injuries with small myocardial infarction should be treated by ligation alone. Proximal injury and those injuries associate with larger area of ischaemia or infarction are best treated with coronary artery bypass. The role of cardiopulmonary bypass pump in these patients should be evaluated depending on the homodynamic stability of the patient. We present two cases of cardiac stab wounds with transection of the left anterior descending (LAD), which were successfully managed. A literature review regarding the management of combined cardiac and coronary artery injuries is also provided.