Holes in the heart: an atlas of intracardiac injuries following penetrating trauma

Darshan Reddy 1 David J.J. Muckart 0 0 Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital , Durban, South Africa 1 Department of Cardiothoracic Surgery, University of KwaZulu Natal, Inkosi Albert Luthuli Central Hospital , Durban, South Africa OBJECTIVES: The extraordinarily high rate of penetrating heart injuries in South Africa provides a substantial denominator from which we derive a subset of patients with intracardiac lesions as a result of these injuries. The surgical literature, which consists largely of case reports and case series, describing various patterns of injury is dated and a review of management in the era of modern imaging and surgical techniques is warranted. CONCLUSIONS: The referral of patients for the repair of intracardiac injuries following penetrating cardiac trauma is often delayed. Symptoms of cardiac failure should be optimized medically prior to undertaking definitive surgical repair, thereby also allowing for detailed preoperative imaging to guide appropriate intervention. Utilizing standard principles of intracardiac shunt repair, as well as contemporary valve repair techniques, favourable surgical outcomes may be reproduced. Percutaneous catheter device techniques may prove useful in patients deemed unsuitable for surgical repair, such as patients with sternal wound sepsis. - INTRODUCTION While the surgical and trauma literature abounds with reports of penetrating cardiac injuries, the body of knowledge regarding intracardiac lesions resulting from these injuries consists of a largely dated collection of case reports and small case series. This contribution, a retrospective institutional review from a trauma epicentre, represents a contemporary view of the subject, focusing on preoperative imaging and surgical repair techniques. PATIENTS AND METHODS The Department of Cardiothoracic Surgery at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, serves as the sole provider of cardiac surgical care for the province of Kwazulu Natal and the Eastern seaboard of South Africa, serving an estimated population of 14 million people. The case records of all patients with intracardiac lesions resulting from penetrating trauma presenting to the department between July 2003 and July 2013 were reviewed. Data were gathered from electronic patient records (including demographics), computerized imaging undertaken [ plain chest radiography, echocardiography, computed tomography angiography (CTA) and conventional catheter angiography (CCA)] and intraoperative photographic images. The indications for surgery of intracardiac shunts and valve apparatus injuries included symptoms related to the haemodynamic abnormality (congestive cardiac failure, failure to wean from ventilation and persistent hypoxemia) or the presence of a ventricular aneurysm with potential for rupture. All patients underwent preoperative clinical cardiological review and transthoracic echocardiography (TTE). CTA was used to further delineate ventricular aneurysms and retained intracardiac foreign bodies, whereas CCA was used to obtain haemodynamic, oximetry and angiography data in patients with intracardiac shunts and fistulae to estimate the shunt fraction and localize lesions. Intraoperative transoesophageal echocardiography (TEE) was used to evaluate repairs when available. Definitive repairs were undertaken via median sternotomy, employing conventional techniques of cardiopulmonary bypass. Repair techniques utilized included ventricular septal defect (VSD) closure; aortic, mitral, tricuspid and pulmonary valve repair; intracardiac fistulae repair and ventricular aneurysm repair. Postoperative intensive care was undertaken in the cardiothoracic surgical intensive care unit (ICU), with follow-up undertaken jointly by the Departments of Cardiothoracic Surgery and Cardiology. Outcomes measured included early mortality and morbidity (including reoperation). The lack of follow-up data limited the consistent measurement of late outcomes. This study was approved by the Biomedical Ethics Review Committee at the University of KwaZulu-Natal (BE303/12). Over the study period, a total of 17 patients (16 males) with documented intracardiac injuries following penetrating thoracic trauma were referred to our institution. The age at presentation ranged from 13 to 52 years, and all patients were initially treated at a local health-care facility, where the primary surgical care included tube thoracostomy for the treatment of a haemothorax in 6 patients, emergency sternotomy or thoracotomy for the relief of cardiac tamponade in 3 patients and pericardial drainage in 2 patients. Upon arrival at our institution, all patients were reviewed by a cardiologist and underwent TTE imaging, with CTA and CCA used selectively as outlined above in the study methods. All patients in congestive cardiac failure underwent a period of in-hospital diuresis prior to definitive surgery, to optimize their condition at surgery and reduce the duration of the postoperative ICU course. Owing to the heterogeneous patient population and injury pattern, details of the 17 cases are tabulated, with definitive management classified as operative and non-operative in Tables 1 and 2, respectively. In the group that underwent surgical correction, 5 of the 10 patients presented with haemodynamically significant VSDs, of which 3 were associated with mitral or tricuspid valve lesions (Fig. 1). These defects were repaired on cardiopulmonary bypass via the tricuspid valve, using various repair techniques appropriate to the configuration of the defect. Circular defects were closed with a double velour Dacron patch and interrupted pledgeted sutures (Fig. 2), whereas linear defects were closed using a direct suture technique buttressed with teflon strips or felt pledgets. None of the patients developed heart block following VSD closure, while 1 patient had a residual VSD shunt necessitating reoperation (described later). Two intracardiac fistulae were encountered; an aortic root to right ventricular outflow tract fistula associated with aortic and mitral valve injuries, and a right main pulmonary artery to left atrial fistula. Fistulae were closed at both ends using a direct polypropylene suture technique, with felt pledgets for additional support. Two patients presented with false aneurysms of the left ventricle; at surgical exploration, one had resolved (Fig. 3) while the other required repair by plication of the communication with the left ventricle using teflon strips (Fig. 4). One patient presented 33 years after injury with an aneurysm of the right ventricular outflow tract involving the pulmonary valve, which was regurgitant due to distortion and leaflet perforation. The aneurysm neck was plicated, and the pulmonary valve leaflets reconstructed with bovine pericardium and commissures resuspended. Three patients required more than one surgical procedure. Patient 4 presented with a VSD and underw (...truncated)