Operative Management of Cardiac Injuries: Diagnosis, Technique, and Postoperative Complications

Curr Trauma Rep (2015) 1:225–231 DOI 10.1007/s40719-015-0032-9 PENETRATING INJURIES TO THE HEART AND LUNG (R NIRULA, SECTION EDITOR) Operative Management of Cardiac Injuries: Diagnosis, Technique, and Postoperative Complications Angela Ingraham 1 & Jason Sperry 1 Published online: 5 September 2015 # Springer International Publishing AG 2015 Keywords Cardiac injury . Penetrating cardiac trauma . Cardiac wounds have detailed the clinical presentation and treatment of various PCI in adults. This review will highlight the most recent advances and controversies in caring for this challenging patient population from pre-hospital management to definitive surgical treatment. Introduction Penetrating cardiac injuries (PCI) are challenging in part because of their lethality and have thus long demanded the respect of physicians [1]. In the early eighteenth century, Boerhaeve designated all penetrating cardiac trauma as fatal [2]. In 1913, Dr. Billroth stated that Bany surgeon who would attempt operation on the heart should lose the respect of his colleagues.^ [3] In 1916, Dixon and McEwen proclaimed, BProbably nearly all cardiac wounds produce death from haemorrhage too quickly to allow the patient being removed alive even to a short distance from the battle field.^ [4] Despite such poor outcomes, attempts were made to salvage the injured patients. In 1829, Napolean’s surgeon D. J. Larrey described a Bnew surgical procedure to open the pericardium in the case of fluid in the cavity.^ [5] The first reported cardiac procedure is that of Alex Cappelen repairing a penetrating injury of the left ventricle through a left anterior thoracotomy in Christiania; the patient died 3 days later [6]. Numerous case reports [3, 7–29] and case series [1, 30–32, 33•, 34•, 35, 36•] This article is part of the Topical Collection on Penetrating Injuries to the Heart and Lung * Jason Sperry 1 University of Pittsburgh Medical Center, Suite F1268 PUH, 200 Lothrop St., Pittsburgh, PA 15213, USA Survival Tenets learned from our surgical heritage continue to be applicable to the current management of penetrating cardiac trauma. Survival after PCI is heavily dependent upon the mechanism and trajectory of the injury, the patient’s physiological status, and expeditious closure of the wound. Gunshot wounds carry a higher mortality than stab wounds due to the larger nature of the wounds and the greater surrounding tissue loss [9, 33•]. In the Los Angeles County-University of Southern California (LA County-USC) trauma registry, survival after stab wounds to the heart was 50.3 % as opposed to 11.5 % for gunshot wounds [33•]. The trajectory of the injury also plays a significant role. Cardiac anatomy determines the injury pattern with the right ventricle most frequently affected followed by the left ventricle, right atrium, and left atrium [8, 9, 37]. The right ventricle composes the majority of the anterior surface of the heart and thus is the most vulnerable to penetrating injuries. The left atrium is the least likely injured because of its small size and well-protected posterior location. Within the LA County-USC trauma registry, patients sustaining an injury to the right ventricle had a survival rate of 31.5 %; left ventricle, 26.1 %; right atrium, 20.5 %; and left atrium, 5.9 % (p<0.001) [33•]. Patients with atrial injuries had a high incidence of injuries to other cardiac chambers and the great vessels. Within the study, 202 patients (49.8 %) had isolated cardiac injuries; of those, 93.1 % had a single cardiac 226 chamber injury, with a survival rate of 46.6 %. This is in contrast to the 95.6 % mortality for patients with multiple chamber cardiac injuries. Finally, in addition to the injury pattern, the time between the injury and definitive care is one of the most important predictors of survival for PCI. Among patients treated for PCI and in cardiopulmonary arrest at the LA County-USC Medical Center, the time from the scene to the hospital was shorter in those who survived to hospital discharge compared with those who died (mean (SD): 4.2 [10.2] vs 21.5 [28.0]min, respectively; p<0.001) [33•]. Mortality Mortality after penetrating cardiac wounds can be due to cardiac tamponade, exsanguination, coronary artery laceration, valvular disturbances, disruption of conduction pathways, or other associated lethal injuries such as mediastinal major vascular injury [17]. Mortality can be reduced with early diagnosis, rapid transportation, resuscitation, and repair. Diagnosis of PCI relies upon clinical exam, ancillary studies, and an appropriate threshold of a suspicion for the injury. Clinical symptoms of PCI may vary from no symptoms to severe hemodynamic instability. The classic physical exam findings of tamponade may not be present in the face of hypovolemia and are only found in approximately 10 % of patients with tamponade [38]. The cardiac silhouette may be enlarged on chest x-ray (CXR); however, at least 250 ml of pericardial fluid must be present to detect heart enlargement radiographically. Electrocardiogram (EKG) may suggest tamponade if the QRS voltage is decreased or if the dominant QRS axis constantly changes (electrical alternans) due to the heart floating in the pericardium. However, it is imperative to remember that a normal EKG or CXR does not rule out cardiac injury [8]. Diagnosis Echocardiography has been increasingly relied upon as a diagnostic tool due to its ease of use, wide availability, noninvasive approach, and reports of 100 % sensitivity, 97 % specificity, and 97 % accuracy [39]. However, echocardiography performed as part of the Focused Assessment with Sonography for Trauma (FAST) is operator dependent and thus can be associated with false-negative results. Additionally, echocardiography is challenging in the presence of obesity, subcutaneous air, or a large left hemothorax and may be negative for pericardial effusion if the blood has decompressed into the left chest [40, 41]. Preoperative or intraoperative transesophageal echocardiography (TEE) is beneficial when transthoracic echocardiography (TTE) is hindered by subcutaneous Curr Trauma Rep (2015) 1:225–231 emphysema, pneumothoraces, and bulky surgical dressings. Beyond identifying a pericardial effusion, preoperative and intra-operative echocardiography can assist in diagnosing valvular damage, chordae or papillary muscle rupture, and defects in the atrioventricular septum [32]. In the hemodynamically stable patient, chest computed tomography (CT) may also serve as a diagnostic tool. A retrospective review of the trauma registry at the HarborUniversity of California Los Angeles (UCLA) Medical Center revealed that hemopericardium and/or pneumopericardium on chest CT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value (PPV) of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, when all findings that changed the course of management (e.g., retained hemothorax, p (...truncated)