Penetrating cardiac injury: a narrative review

Introduction

Cardiac injury previously was almost fatal, as described in the death of Sarpedon from an impalement of a lance to the heart in the Iliad (1). Hippocrates (2), Aristotle (3), Galen (4), Fabricius (5) and Boerhaave (6), all described such wounds to the heart as futile. While once universally fatal, penetrating cardiac trauma still has life-threatening implications. It is important to understand the how to promptly diagnose and manage these injuries to maximize survival. Despite advances in prehospital care, in-hospital protocols and surgical techniques patients can still decompensate quickly with penetrating cardiac injuries. The purpose of this article is to better characterize the history and present treatment of penetrating cardiac trauma in the form of a narrative review. The rationale for creating this review is to combine the literature with expert experience to help guide future research and clinicians to better treat penetrating cardiac injury. We present the following article in accordance with the Narrative Review reporting checklist (available at https://med.amegroups.com/article/view/10.21037/med-22-18/rc).

Methods

A narrative review was preformed synthesizing literature from MEDLINE and bibliographic review from identified publications as seen in the reference section. The search strategy is summarized in Table 1. Medical Subject Headings (MeSH) terms were used. Search terms included: penetrating trauma OR polytrauma OR cardiac trauma OR penetrating cardiac trauma OR cardiac injury OR thoracic trauma OR emergency thoracotomy. All abstracts were further screened by primary author Hromalik LR Jr. and qualitatively analyzed to include articles with penetrating cardiac injury. A focus was made on articles that presented an aspect of the history, incidence, etiology, presentation, diagnosis or treatment of penetrating cardiac injury. Papers were primarily in English but other texts were reviewed if there was an English translation available. Older texts and translations cited in the ‘Introduction’ and ‘History’ that are not primarily medical research were found utilizing Google Scholar and with review of texts at University of Hawaii Libraries.

History

The earliest interventions were described by Morgagni (7) in 1761 who described the compressive effects of blood by the heart. Larrey (8) was credited for pioneering the technique of a pericardial window. Ludwig Rehn performed the first successful repair of a cardiac injury on September 9, 1896 in Frankfurt (9). Exposure of the heart after penetrating trauma evolved at the turn of the century when Duval (10) first described the median sternotomy incision, while Spangaro (11) in 1906 described the left anterolateral thoracotomy incision. The diagnosis of cardiac injury evolved in 1926 when Beck described the Triad physiology of cardiac tamponade. He also described an important repair technique that is still used today. This technique involves placing mattress sutures under the coronary vessels to spare ligation for lacerations to the heart (12,13). Treatment was then further developed by Harken (14) in 1946 who described the removal of foreign bodies adjacent to the heart and great vessels. Treatment was then extended beyond the operating room by Beall (15-18) who first described emergency department thoracotomy (EDT) and along with Cooley (17) who reported the potential benefits for cardiopulmonary bypass in the management of selected intracardiac injuries. Mattox (19-21) further protocolized the use of EDT and cardiorrhaphy including emergency cardiopulmonary bypass.

Incidence

Penetrating cardiac injuries are uncommon and represent a small fraction of penetrating trauma overall. Penetrating cardiac trauma is often described in high volume urban trauma centers (22-30). Iatrogenic penetrating cardiac injury can be also seen in any clinic or hospital, following procedures. Iatrogenic penetrating cardiac trauma is most often seen following pericardiocentesis. The true incidence of injury overall is difficult to quantify but various centers have described their experiences. Feliciano (22) described in a one-year experience 48 cardiac injuries at Ben Taub Hospital in Houston. Mattox (23) in 1989 described a 30-year experience from the same institution, reporting 539 cardiac injuries. Asensio (24,31) reported a total of 165 cardiac injuries within a 3-year period at LA County/USC hospital in Los Angeles. Tyburski (32) in 2000 reported an 18-year experience of 302 patients with penetrating heart injuries undergoing emergency thoracotomy. Seamon (26) described 207 cardiac injuries over 7 years between Temple University Hospital and the Hospital of the University of Pennsylvania. Clarke (28) described 206 cardiac injuries in South Africa over a 3-year period. The overall incidence varies by geographic location and is also influenced by violent crimes involving the use of firearms or penetrating objects (22-32).

Etiology

In the civilian setting, penetrating cardiac injuries are usually seen as a result of gunshot wounds and stab wounds. A subset of cardiac injuries are seen from iatrogenic needles, trocars, and catheters (33-39).

In the military setting, most patients do not survive cardiac injuries from high velocity automatic rifles in battle. The majority military reported injuries are from fragments of grenades or shrapnel. Rich (40) reported such injuries in 96 patients from the Vietnam conflict, arriving at treatment facilities. Hughes (41) describes over 2,000 thoracic injuries over 10 years during the Afghanistan and Iraq conflicts.

Clinical presentation

Most cardiac injuries from stab wounds will follow the trajectory of the insult. Gunshot wounds are different because they can cause injury from precordial and extra-precordial entrance sites (42). Hirshberg (43) described 26% associated cardiac injuries in 41 patients presenting with combined thoracoabdominal injuries, while Asensio (44) reported a 44% incidence of associated penetrating cardiac injuries in his series of 73 patients who sustained thoracoabdominal injuries.

Penetrating injuries to any of the cardiac chambers may quickly lead to acute cardiac tamponade and death. Hemorrhage through a lacerated pericardial injury will flow into the hemithorax and will lead to death. The pericardium can therefore prevent fatal exsanguination and allow patients survive long enough to reach the trauma center alive. They may have varying degrees of hemodynamic instability secondary to pericardial tamponade (24,31). Interestingly, the classic presentation of Beck’s Triad (muffled heart sounds, jugular venous distension and hypotension) or Kussmaul’s sign (jugular venous distension with inspiration) are only present in 10% of patients who present with pericardial tamponade (42).

Moreno (45) did a retrospective study that looked at 100 patients with penetrating cardiac injuries and reported higher survival 77% vs. 11% in patients who present with pericardial tamponade. Moreno also showed that right-sided chamber injuries confer a higher survival 79% vs. left-sided chamber injuries of 28% survival.

Diagnosis

The clinician should always be concerned for cardiac injury when patients present after sustaining any penetrating injury. If the patient is hemodynamically stable and has a widened mediastinum on chest X-ray the clinician should also have a high suspicion for cardiac injury. Sonography is an excellent tool that can determine the presence of pericardial fluid. Physical exam findings of Beck’s triad or Kussmaul’s sign can also be supportive but not always present. Any injury with a concern of direct trajectory towards the heart should prompt preparation for a possible emergent bedside anterolateral thoracotomy should the patient acutely decompensate.

Subxiphoid pericardial window

The reliability of subxiphoid pericardial window technique vs. pericardiocentesis has been controversial in the evaluation and treatment of penetrating cardiac injury (46-54). These techniques may be useful in the absence of two-dimensional echocardiography. While these techniques might demonstrate hemopericardium, they are time consuming. In addition, a pericardial window may result in exposing a cardiac injury through a very small incision and may need a larger secondary thoracic operation. A transdiaphragmatic pericardial exploration at the time of a laparotomy (55) has been described in cases where patients have sustained combined thoracoabdominal injuries. Laparoscopic transdiaphragmatic pericardial window also has been described for more stable patients (56-58). However, if there is an injury found, they still may need a larger secondary operation for optimal exposure of the heart and treatment.

Two-dimensional echocardiography

Echocardiography has now become the gold standard in the initial diagnosis and evaluation of patients with penetrating thoracic injury. The diagnosis is made by looking for hemopericardium. It is fast, and easily reproducible (42,55,59-61). Governatori (61) performed a review of multiple studies that show echocardiography has a high accuracy up to 96–97% with sensitivity and specificity reaching near 100%. Echocardiography can also be used to further delineate some intramyocardial foreign bodies vs. missiles located within the cardiac chambers (62-64). We recommend use of sonography to look for pericardial fluid in all patients with concern for penetrating cardiac injury because it is fast, reproducible and can influence operative management.

Management

Patients with penetrating cardiac injury may have a fatal outcome regardless prehospital intervention. In the select group that are stable enough for transport to the trauma center, the time between initial injury and release of cardiac tamponade is of utmost importance. This prehospital course is marked by certain surrogate parameters for either improved or dire prognosis.

Under no circumstances should EMS personnel delay transport by insertion of intravenous lines—this should be carried out during transport. Concomitant notification of the trauma center to activate the trauma team is also of paramount importance (42). Gervin (65) demonstrated a survival advantage if patients are transported to the trauma center is within 9 minutes, while all patients succumbed when transport was greater than 25 minutes. Mattox (66) found no survivors in 100 patients who had received external cardiac compression for more than 3 minutes in the prehospital period and were not intubated. Lorenz (67) associated better survival if patients had systolic blood pressures of 60 mmHg or more in the field and upon arrival in the emergency department. Durham (68) showed the average survival was seen with 5 minutes or less of cardiopulmonary resuscitation, but this time improved to 9 minutes when prehospital intubation was performed.

Upon arrival to the emergency department, the trauma team should be ready to perform advanced trauma life support or immediately transport patients from the ambulance bay to the operating room (69). Patients can be grouped into multiple categories based on stability. The hemodynamically stable patient can allow time for expedited yet detailed workup. The unstable patient that responds to initial fluid resuscitation may have the opportunity to be transported to the operating room for a life-saving operation. Patients who present or go into cardiopulmonary arrest will require EDT (24,31,42,70,71). EDT, if performed under strict indications for cardiac injuries, has been shown to improve survival rate as much as 31% (72). Rhee (73) preformed a large systematic review looking survival after EDT with respects to location, mechanism of injury and signs of life on arrival. It was shown that patients with penetrating cardiac injury and with signs of life on arrival yielded the highest survival among those who underwent EDT. Seamon et al. (74) reviewed 72 studies of patients undergoing EDT. They compared outcomes by presentation for location, mechanism, pulse status, and signs of life. Signs of life were defined as: pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement or cardiac electrical activity. They strongly recommend that EDT should be performed in patients who present pulseless with signs of life after penetrating thoracic injury.

Techniques for cardiac injury repair

Incisions

Median sternotomy and left anterolateral thoracotomy are the two incisions of choice for cardiac injuries. The median sternotomy is preferred in patients who are treated for anterior stab wounds to the chest, and for those who arrive in some degree of hemodynamic instability, but stable enough for work up with sonographic or chest x-ray imaging. The left anterolateral thoracotomy is the incision of choice in the management of patients that arrive in extremis. This incision is also used as EDT for emergent resuscitative purposes (24,31,42,70,75). A bilateral transsternal anterolateral thoracotomy can provide optimal exposure of the mediastinum and both hemi-thoracic cavities if necessary.

Adjunct maneuvers

Exposure of the heart to repair posterior injuries can be accomplished in several ways. The Heart can be retracted using sutures. Temporary pledgeted sutures can be placed on the apex of the heart with the sutures cut long in order to slowly retract the apex superiorly to gain access to the posterior injury. Alternatively, a Satinsky clamp can also be used on the right ventricular angle to achieve the same exposure (76). A simple option that we recommend is to place folded wet towels sequentially behind the heart in order to gradually lift the heart up to provide exposure without causing the heart to go into an arrhythmia. Stabilizing devices can also be used to help provide exposure but require time to set up. It is important to be careful with placement of repair stitches on laceration injuries to avoid causing further tear injury.

Total inflow occlusion of the heart can also be performed by placing clamps on the intrapericardial location to isolate and repair injuries at the level of atriocaval junction. This will often cause the heart to fibrillate, requiring paddle defibrillation and pharmacologic intervention (42,75). It is important to remember that the heart should be intermittently compressed as cardiorrhaphy is performed in case defibrillation is necessary. Failure to decompress the heart before defibrillation can cause further injury to the heart.

Repair of atrial injuries

Exposure of atrial injuries is relatively straight forward. Right atrial injuries can usually be stabilized and controlled with a Satinsky clamp (77,78) followed by repair using 4-0 non-pledgeted polypropylene monofilament sutures. The atrium is thin walled and tears easily, so it is important to be gentle with traction of sutures to avoid further injury or tearing.

Repair of ventricular injuries

Blast injuries resulting from gun shots to the ventricle can damage the epicardium and myocardium making them more friable and unforgiving with standard suture repair. The repair can be further complicated by tachycardia or high-pressured bleeding. Left ventricle injuries will also have higher. Depending on the size of the injury, 2-0, 3-0 or 4-0 polypropylene can be used for repair. Many surgeons suggest that pledgeted sutures should be used for repair however they have not been demonstrated to have any benefit over a carefully placed suture in the horizontal mattress fashion. Commercial brand fibrin sealant (78,79) are also often recommended but have also not been proven to add any value or benefit over suture repair.

Coronary artery injuries

Direct coronary artery injuries can be challenging to repair. Proximal injuries will require cardiopulmonary bypass, especially if there is gross evidence of cardiac ventricular dysfunction. Distal coronary artery injuries can potentially be ligated. Specifically, if the distal third of the vessel is injured/lacerated there may be little benefit in bypass. Bypass may not be necessary if the heart remains without ventricular dysfunction and tolerates ligation. Off-pump bypass can also be an option in select patients (80). Cardiac injuries in close proximity to coronary arteries may be managed with carefully placed horizontal mattress sutures underneath the coronary vessel for safe repair, taking care not to narrow or occlude the coronary artery in the process (42,70,77,81-83).

Complex and combined injuries

These can be defined as penetrating cardiac injury in addition to associated thoracic, thoracic-vascular, neck, abdominal and abdominal-vascular, or peripheral vascular injuries. Priority should be given to treatment of injury with the greatest risk of blood loss or is most life-threatening (42,70,77,84-89).

Wall and Mattox (90) described complex cardiac injuries as those beyond lacerations of the myocardium. These injuries often include concomitant coronary artery injuries, cardiac valvular injuries, intracardiac fistulas, ventricular false aneurysms and coronary sinus injuries. These may be addressed by the cardiac surgeon once the other life-threatening injuries are temporized and dealt with. Priority should always be limiting blood loss and stabilizing patient before definitive repair is undertaken.

Limitations

There are many limitations to this narrative review. First, this is not a systematic review of all research regarding penetrating cardiac trauma, and we do not specifically compare the overall quality of research included in our review. We have included relevant literature regarding the history, incidence, etiology, diagnosis, and treatment to provide guidance in the care of patients with penetrating cardiac injury.

Conclusions

Penetrating cardiac injury should prompt a quick comprehensive workup. Workup should include a sonographic exam that is useful to diagnose pericardial fluid indicating the need for operative treatment. In the hemodynamically stable patient, the workup can be more extensive and include CT imaging studies. An anterolateral thoracotomy can be used in the emergent setting to cross clamp the descending aorta in order to perform necessary cardiac repairs. A median sternotomy should be used in a more stable patient with identified cardiac injuries to optimize exposure and perform definitive repair. Our recommendations for exposure and repair techniques should be considered to optimize survival in all penetrating cardiac traumatic injuries. Future studies and policies should focus on refining trauma algorithms to include optimizing prehospital care and transport. Future research and policy should be driven with collaboration between high-volume, urban trauma centers that routinely care for penetrating cardiac injuries.

Acknowledgments

Larry R. Hromalik Jr, MD, would like to thank Peter I. Tsai, MD, FACS (Professor of Surgery, JABSOM, University of Hawaii), Matthew J. Wall, Jr., MD, FACS (Professor of Surgery, Baylor College of Medicine, TX) and Kenneth L. Mattox, MD, FACS (Distinguished Service Professor Emeritus, Baylor College of Medicine, TX) for their mentorship, patience, contribution of knowledge and combined vast experience that enabled the completion of this project.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Simon R. Turner) for the series “Traumatic Injuries of the Mediastinum” published in Mediastinum. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://med.amegroups.com/article/view/10.21037/med-22-18/rc

Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-22-18/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-22-18/coif). The series “Traumatic Injuries of the Mediastinum” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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