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

ORIGINAL ARTICLE – ADULT CARDIAC Interactive CardioVascular and Thoracic Surgery 19 (2014) 56–63 doi:10.1093/icvts/ivu077 Advance Access publication 21 March 2014 Holes in the heart: an atlas of intracardiac injuries following penetrating trauma Darshan Reddya,* and David J.J. Muckartb a b Department of Cardiothoracic Surgery, University of KwaZulu Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa * Corresponding author. Department of Cardiothoracic Surgery, University of KwaZulu Natal, Inkosi Albert Luthuli Central Hospital, Private Bag X03, Mayville, Durban 4058, South Africa. Tel: +27-0312401000; fax: +27-0312402113; e-mail: (D. Reddy). Received 30 October 2013; received in revised form 11 February 2014; accepted 25 February 2014 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. METHODS: A retrospective observational chart review of all patients with intracardiac injuries following penetrating trauma who were referred to the Department of Cardiothoracic Surgery at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, during the 10-year period between July 2003 and July 2013 was performed. The spectrum of pathology encountered included ventricular septal defects, valve apparatus lacerations, intracardiac fistulae, ventricular aneurysms and retained intracardiac missiles. RESULTS: Of the 17 patients, 10 required operative repair of the intracardiac lesions using cardiopulmonary bypass, with no early mortality noted. Seven patients were treated non-operatively, for reasons that varied from insignificant haemodynamic shunts to advanced human immunodeficiency virus (HIV) infection. The in-hospital mortality in this group consisted of 1 patient, who was moribund at presentation. 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. Keywords: Trauma ( penetrating) • Echocardiography • Septal defects • Heart valves • Ventricular aneurysms 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; © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Abstract 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). RESULTS interrupted pledgeted sutures, was reinforced with felt strips. Following an unsuccessful attempt at mitral valve repair, the valve was replaced using a 27/29 On-X mechanical prosthesis (On-X Life Technologies, Inc., Austin, TX, USA). This patient returned in acute pulmonary oedema 17 months later with a thrombosed mechanical prosthesis, necessitating emergency reoperation. Patient 5 presented with a wooden spike penetrating the pericardium and traversing the right pulmonary artery and left atrium (Fig. 5). The spike was extracted via right thoracotomy, followed by further imaging which illustrated a right pulmonary artery to left atrial fistula. This was repaired via median sternotomy 3 days later. Patient 6 underwent surgical repair of the aorto-right ventricular fistula, with concomitant aortic and mitral valve repair using a direct suture closure of the perforations (Fig. 6). Early postoperative echo demonstrated residual moderate mitral regurgitation, which progressed to severe regurgitation necessitating mitral valve repair 11 months later. At reoperat (...truncated)