1. Operative Management of Penetrating Cardiac Injuries Daniel Pust, MD

2.  Hippocrates stated that all wounds of the heart were deadly  Ambrose Pare, a French trauma surgeon described two cardiac injuries from autopsie studies in 1643 Wolf in 1642 described the first healed cardiac wound

3.  Cappelen from Norway repaired the first cardiac injury, a 2 cm left ventricular laceration including ligation of a brunch of the LAD in 1895  Farina in Italy repaired a left ventricle in 1896  both patient died  Rehn in Germany repaired successfully a wound of a right ventricle in 1896  Hill in the US repaired successfully a left ventricular injury in 1902

4.  Duval described the median sternotomy incision in 1907  Spangaro described the left anterolateral thoracotomy incision in 1907  Beck in 1942 described the technique of placing mattress sutures under the bed of coronary arteries

5.  Griswold recommended that every large general hospital should have a sterile set of instruments and an operating room available 24 hours a day

6.  Beall was the first who described the emergency room thoracotomy  Mattox et all refined and protocolized ER thoracotomy and cardiorraphy including the use of cardiopulmonary bypass

7.  Mattox et al described the 30 year experience at Ben Taub hospital in Houston with 539 cardiac injuries ( 18 / year)  Asensio et al: two series with a total of 165 cardiac injuries in 3 years at LAC

8.  63 % GSW  36 % SW

9.  Beck’s triad: muffled heart sounds, jugular venous distention, hypotension  only seen in 10 % of cases  Patients may present with normal vital signs or be in shock and not uncommon if full cardiac arrest  Cardiac tamponade

10.  Moreno et al reported 100 patients with penetrating cardiac injuries  77 had pericardial tamponade  The survival rate of patients presenting with cardiac tamponade was much higher 73 % versus 11% thereby ascribing tomponade a protective affect

11.  However Asensio et al did not show any protective effect of cardiac tamponade in 105 patients presenting with penetrating cardiac injury

12.  Physical examination  May present hemodynamically stable or unstable or in cardiac arrest  Often associated hemopneumothoraxes  FAST US to evaluate for tamponade  Does not rule out cardiac injury

13.  Penetrating cardiac injury with cardiac arrest: ER thoracotomy  Suspected cardiac injury and hemodynamically unstable immediate transfer to OR for thoracotomy or sternotomy  Suspected cardiac injury and hemodynamically stable: OR for pericardial window

14.  Indication: penetrating thoraxic or abdominal trauma in cardiac arrest  Cardiac arrest during transport or in trauma bay  1. control of airway with intubation and mechanical ventilation  2. left anterolateral thoracotomy  3. simultaneously right side chest tube and right subclavian introducer line

15.  1. evacuation of pericardial tamponade  2. control of massive hemorrhage  3. repair of cardiac injuries  4. internal cardiac massage  5. aortic cross clamping  6. prevention of air emboli 

16.  Incision: left anterolateral thoracotomoy starting at the left sternal boarder, extending below the nipple line all the way to the latissimus dorsi muscle  Sharp transection of intercostal muscles and parital pleura  Placement of Finochietto retractor  Elevation of left lower lunge lobe medially

17.  Blunt dissection of thoracic aorta just above the diaphragm  Encircled between the thumb and index finger  Placement of aortic cross clamp  longitudinal opening of the pericardial sac is made anterior to the phrenic nerve using Metzenbaum scissors  Evacuation of blood clot

18.  Immediately note the presence or absence and type of cardiac rhythm  Location and control of cardiac injuries  Digital control of cardiac injury and simultaneous suture repair to control further hemorrhage  Prolene 2-0 or 3-0  Sometimes balloon control using a Foley catheter, however that may enlarge the injury

19.  Some use staples for temporary control  Atrial injuries can be controlled temporally by placement of a Satinsky clamp or Allice clamps  Internal defibrillation with 30-50 J for ventricular fibrillation  Pharmacologic support  If cardiac rhythm and PB restored transfer to OR for permanent repairs \

25.  Asensio 2006: 47 / 830  Mattox 1985: 50 / 119  Ivatury 1987: 28 / 91  Tyburski 2000: 12 / 152

26.  Duval median sternotomy vs Spangaro anterolateral thoracotomy

28.  Adjunct Maneuvers:  Total inflow occlusion of the heart:  Complex maneuver  Cross-clamping of SVC and IVC in their intrapericardial location

29.  Arrest total blood flow to the heart  Indicated for lateral atrial injuries  1- 3 minute time  Cross-clamping of pulmonary hilum  Indicated for associated pulmonary injuries with active bleeding within the hilum Often poorly tolerated by the right ventricle

30.  Elevation of the heart to reach posterior injuries  Slow elevation by placing multiple laparotmoy pads  Elevation of the heart leads often to arrhythmias

31.  Initially can be often controlled by placement of a Satinsky clamp ( partial occlusion)  Monofilament suture of 2-0 Polypropylene on a MH needle  Running or interrupted fashion  Teflon pledges are not recommended for atrial injuries

34.  Should be digitally controlled  Horizontal mattress sutures of Halsted  Pledgets or Teflon strips are often needed to buttress the suture line  2-0 Prolene on MH needle  Injuries close to a coronary vessel is repaired by using a horizontal mattress of Halsted with the suture placed underneath the bed of the coronary vessel to avoid narrowing of the vessel

39.  Divided into 3 segments:  Proximal, middle, distal  Proximal and middle segment require repair  Often requires cardiopulmonary bypass or at least stabilization system  distal segments can be ligated 

40.  Grade I:  Blunt cardiac injury with minor ECG abnormality (nonspecific ST or T wave changes, premature atrial or ventricular contraction or persistent sinus tachycardia)  Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade or cardiac herniation

41.  Grade II:  Blunt cardiac injury with heart block or ischaemic changes without cardiac failure  Penetrating tangential cardiac wound up to but not extending through endocardium, without tamponade

42.  Grade III  Blunt cardiac injury with sustained or multifocal ventricular contractions  Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction or distal coronary artery occlusion without cardiac failure  Blunt pericardial laceration with cardiac herniation  Blunt cardiac injury with cardiac failure  Penetrating tangential myocardial wound up to but not through endocardium, with tamponade

43.  Grade IV:  Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction or distal coronary artery occlusion producing cardiac failure  Blunt or penetrating cardiac injury with aortic or mitral incompetence  Blunt or penetrating cardiac injury of the right ventricle, right or left atrium

44.  Grade V:  Blunt or penetrating cardiac injury with proximal coronary artery occlusion  Blunt or penetrating left ventricular perforation  Stellate injuries <50% tissue loss of the right ventricle, right or left atrium

45.  Grade VI:  Blunt avulsion of the heart  Penetrating would producing >50% tissue loss of a chamber

46.  Asensio et al showed correlation between AAST-OIS with mortality rate:  Grade IV: 56 %  Grade V: 76%  Grade VI: 91%