How to mend a broken heart: a major stab wound of the left ventricle

Delayed Cardiac Rupture Induced by Traumatic Myocardial Infarction: Consequence of a 45-Magnum Blast Injury; A Comprehensive Case Review

A penetrating chest trauma, a myocardial contusion or a myocardial infarction can lead to a cardiac rupture, which is linked to an extreme high death rate. Only few cases with delayed perforation of the myocardium have been reported in literature. We report about a penetrating gunshot injury, which led to a myocardial contusion with secondary delayed rupture of the left ventricle and the left inferior lobe of the lung. The leakage of the lesion in the left ventricle could be sealed sufficiently with fibrin-coated collagen fleeces after adapting stitches with Prolene 2-0. For additional stabilization of the vulnerable myocardium area, a bovine patch has been placed on the damaged ventricle. Fibrin fleeces are used successfully in cardiac surgery, as in our case, to seal the leakage of the lesion in the left ventricle. The implantation of a bovine patch in the pericardium could prevent a cardiac compartment syndrome with a fatal pericardial tamponade. To prohibit a thoracic compartment syndrome a modified Bogota bag could be sewed in for temporarily closure of the chest. In most cases penetrating cardiac injuries can be treated without heart-lung-machines. An immediate transfer to a cardio-surgical center is, due to the acute situation, not possible. If a surgeon with thoraco-surgical expertise is present a transfer is not absolutely necessary.

Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma center

BACKGROUND

Penetrating cardiac injuries in Europe have been poorly studied. We present a 10-year outcome for patients with penetrating heart injuries at Oslo University Hospital.

METHODS

Data from 01.01.2001 until 31.12.2010 was collected from the Oslo University Hospital Trauma Registry and from the patients' records.

RESULTS

Thirty-one patients were admitted with a penetrating cardiac injury. Fourteen patients survived (45%). Four out of 8 patients (50%) with gunshot wounds survived compared to 10 out of 23 (44%) with stab wounds. Median (quartiles) for the following values were: Injury Severity Score 25 (21-35), Revised Trauma Score 0 (0-6,9), Probability of Survival 0,015 (0,004-0,956), Glasgow Coma Scale 3 (3-13). Thirteen patients had signs of life on admission and survived. Eighteen patients were admitted without signs of life and received emergency department thoracotomy. Eight of these had no signs of life at the scene of injury and did not survive. Out of the remaining 10 patients, one survived.

CONCLUSIONS

The outcome of patients with penetrating cardiac injury reaching the emergency department with signs of life was excellent. Hemodynamic instability indicates immediate surgery. Stable patients with penetrating thoracic trauma and possible cardiac injury detected by imaging should be considered for conservative treatment.

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.