Chapter 56: Cardiac Wound Repair

INTRODUCTION

Wounds of the heart are highly lethal. Traumatic cardiac penetration carries a 70% to 80% fatality rate.¹ Major factors determining survivability include whether or not cardiac standstill has occurred as well as the amount of tissue destruction sustained from the injury.² A repair of a cardiac wound was first described in the literature in 1893.³

Penetrating wounds can be caused by knives, bullets, ice picks, and (infrequently) rib or sternal fragments. Regardless of the offending agent, repair must be done as expeditiously as possible. The right ventricle is the most frequently injured chamber.⁴ However, injury to the heart may occur at more than one site. This is especially true with gunshot wounds.¹

The treatment goal in the Emergency Department is temporary hemostasis. Many different techniques of cardiorrhaphy have been described. We will limit our discussion to five possible approaches to dealing with these injuries (i.e., digital or Foley catheter occlusion, vascular clamps, staples, and sutures).

ANATOMY AND PATHOPHYSIOLOGY

The heart is contained within the pericardial sac. Numerous portions of the heart are exposed behind the anterior chest wall (Figure 48-2). This includes the right ventricle, left ventricle, right atrium, left atrium, aorta, pulmonary artery, and inferior vena cava. These structures are vulnerable to injury behind the anterior chest wall.^5,6 The surface areas that each of these structures contributes to the anterior cardiac silhouette are as follows: 55% right ventricle, 20% left ventricle, 10% right atrium, 10% aorta and pulmonary artery, 4% inferior vena cava, and 1% left atrium.⁷ These numbers also reflect, roughly, the anatomic incidence of injury with cardiac trauma.⁷ Traumatic injury to any of these structures can result in a pericardial effusion and cardiac tamponade. Injuries to more than one cardiac chamber can occur from a single gunshot or stab wound.^4,8 Cardiac wall injuries can also occur following blunt trauma.⁹

INDICATIONS

Any penetrating injury to the heart requires immediate and temporary repair to prevent the patient from exsanguinating. A bluish hue behind the pericardium or a tense pericardial sac after penetrating trauma suggests an underlying cardiac injury. A pericardiotomy should be performed, any blood and clot removed from the pericardial sac, and the heart explored for the site of injury. The indications to perform a thoracotomy are described in Chapter 54.

CONTRAINDICATIONS

The only absolute contraindication to performing a cardiorrhaphy is if the patient has obvious signs of death. It should not be performed if the patient has not had any vital signs for over 15 minutes, as anoxic brain injury is irreversible. It is also contraindicated in patients with penetrating chest trauma who do not meet the criteria for performing an anterolateral thoracotomy. Refer to Chapter 54 for a discussion in ...