Chapter 44. Cardiac Wound Repair

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

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. However, injury to the heart may occur at more than one site. This is especially true with gunshot wounds.

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).

The heart is contained within the pericardial sac. Numerous portions of the heart are exposed behind the anterior chest wall (Figure 36-2). 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.3,4 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.5 These numbers also reflect, roughly, the anatomic incidence of injury with cardiac trauma.5 Traumatic injury to any of these structures can result in a pericardial effusion and cardiac tamponade.

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 42.

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 (Chapter 42).

• Sterile gloves and gown
• Face mask with an eye shield or goggles
• Silk suture, 4-0 and 5-0 (or Prolene)
• 2-0 silk, on a semicircular atraumatic needle
• 10 in. needle driver
• Foley catheter, sizes 14 to 20 French
• Satinsky, or other, atraumatic vascular clamp (Figure 44-1)
• Allis clamps
• Defibrillator with internal cardiac paddles
• Mayo scissors
• Metzenbaum scissors, curved
• Teflon pledgets
• Sterile saline
• 20 mL syringe
• Standard skin stapler, 6 mm wide staples
• Laparotomy pads
• Gauze 4 × 4 squares
• Hemostats

No preparation is required other than that of performing a thoracotomy and a pericardiotomy (Chapter 42). The patient should be intubated, ventilated with 100% oxygen, and fully monitored (i.e., telemetry, a noninvasive blood pressure cuff, and pulse oximetry). Instruct a nurse to administer intravenous broad spectrum antibiotics that cover skin flora, gram-positive organisms, and gram-negative organisms. The Emergency Physician should wear full personal protective equipment to protect themselves from contact with the patient's blood and body fluids. While time is of the essence and this is an emergent procedure, aseptic technique should be followed.

Bleeding from a cardiac wound should ideally be stopped by placing a finger over the wound and immediately transporting the patient to the Operating Room for definitive repair. Unfortunately, the Anesthesiologist, Surgeon, and/or Operating Room may not be immediately available. If the Emergency Physician performs a thoracotomy, they should be versed in methods of temporary cardiac wound repair. Several techniques are available to control hemorrhage from a cardiac wound.

Control of the Heart

It is extremely difficult to maintain a finger over a cardiac wound or to stitch a cardiac wound if the heart is beating. An apical traction suture known as Beck's suture can be placed to control the heart (Figure 44-2). The apex of the heart is the ideal site because it is often away from most lacerations, is a thick portion of the heart, and is away from any major coronary arteries. Place a 2-0 silk suture through the apex of the heart and remove the needle from the suture. The ends of the suture can be grasped by hand or with a hemostat to elevate and control the heart while it is beating.

Sauerbruch Maneuver

Large cardiac wounds and wounds with significant bleeding are difficult to repair, as the blood obscures the surgical field. Experienced Surgeons may temporarily clamp the inferior and superior vena cava to maintain a bloodless field. Clamping the vena cava should not be performed by an Emergency Physician, as it is time-consuming and can injure other structures. A quicker and safer alternative is the Sauerbruch maneuver, or grip, to partially occlude venous inflow through the inferior and superior vena cava (Figure 44-3). This technique will stabilize the heart for wound repair and allow the bleeding site to be identified and repaired.

Insert the nondominant hand into the pericardial cavity and toward the vena cava. Place the middle finger behind the vena cava and the index finger in front of the vena cava (Figure 44-3). The thumb should be resting on the anterior surface of the heart. The ring and little fingers should be resting on the posterior surface of the heart. Use the thumb and the ring and little fingers to cradle the heart while apposing the middle and index fingers to partially occlude the vena cava. This technique can be used to control hemorrhage from the heart, great vessels, or hilum. While effective at controlling hemorrhage, this technique will significantly reduce cardiac output and result in cardiac arrest. The grip should be released every 30 to 60 seconds to ensure coronary artery perfusion.

Digital Occlusion

Digital occlusion of small cardiac wounds can provide excellent hemostasis while awaiting definitive repair. Once a finger is placed on or over the defect, it must remain there until the appropriate materials to perform cardiorrhaphy are available. Do not place a finger into the defect as this may increase the size of the wound. Unfortunately, the fingertip often slips off the wound if the heart is beating. The fingertip interferes with visualization and repair of the wound. It also places the healthcare worker at risk for a needle-stick injury while attempting to repair the wound.

Foley Catheter Technique

A Foley catheter may be used to provide temporary hemostasis. As with digital occlusion, this is only a temporizing measure. Inflate the cuff of the Foley catheter with sterile saline to check its integrity and look for leaks. Deflate the cuff. Place a hemostat on the Foley catheter 3 to 4 cm proximal to the cuff. This will prevent air from being drawn through the catheter and causing an air embolism.

Identify the location of the cardiac wound (Figure 44-4A). Insert the Foley catheter through the cardiac wound until the balloon is within the cardiac chamber (Figure 44-4B). Release the hemostat, inflate the cuff with 10 to 20 mL of sterile saline, and reclamp the Foley catheter (Figure 44-4C). This step should be done quickly to prevent air from being drawn through the Foley catheter.

Apply gentle traction to the catheter (Figure 44-4D). Apply just enough traction to mostly occlude the wound and slow the bleeding. A small amount of bleeding is adequate and acceptable to visualize the wound and perform a temporary repair. Do not try to provide complete hemostasis. This will result in excessive traction on the Foley catheter causing the cuff to pull through the wound, enlarge the wound, and further lacerate the myocardium.

Repair the cardiac wound. Place a purse-string suture around the wound (Figure 44-4E). Use caution when placing the suture so that the needle does not pierce and rupture the cuff of the Foley catheter. The Foley catheter may be advanced into the cardiac chamber temporarily while the suture is being placed. This will prevent the needle from piercing the cuff. Do not advance the cuff too far into the heart and for too long a time period. The cuff may occlude blood flow through the valves and result in cardiac arrest. After the purse-string suture is placed, deflate the cuff and quickly remove the Foley catheter (Figure 44-4F). Tie the ends of the suture to close the cardiac wound (Figure 44-4G). Place additional knots to secure the suture.

The Foley catheter technique is simple and effective. It avoids the problems associated with digital occlusion. The catheter may be placed in posterior cardiac wounds that are difficult to visualize and where it is hard to maintain digital occlusion. The Foley catheter does not interfere with visualization of the wound, wound repair, or the simultaneous performance of cardiac massage. Intravenous catheter tubing may be inserted into the lumen of the Foley catheter to infuse crystalloid solutions or red blood cells directly into the heart and central circulation. This technique is especially valuable in repairing wounds at the junction of the right atrium and vena cava.

Clamp Technique

Atrial wounds can bleed profusely and are difficult to control. The thin walls do not allow digital occlusion to be effective. The atrial wound can be grasped and compressed between the thumb and index finger. An atraumatic Satinsky vascular clamp can be placed around the wound to provide hemostasis (Figure 44-5). The wound may then be repaired with 4-0 or 5-0 interrupted silk sutures.

Allis clamps may be substituted if an atraumatic vascular clamp is not available. Place an Allis clamp on each of the opposing edges of the atrial wound. Apply upward traction, then cross the Allis clamps to approximate the wound edges. The wound may now be sutured closed. The Allis clamps do not provide as bloodless a field as does the atraumatic vascular clamp.

Staple Technique

Skin staplers provide a quick and easy method to repair cardiac wounds. Careful approximation and stapling of the wound will rapidly close the defect and aid in controlling massive blood loss. Staples may be used to close small, large, or multiple lacerations. Its use avoids the potential complication of a needle stick to the Emergency Physician.

Cardiac wounds are closed similarly to skin lacerations (Figure 44-6). Obtain a standard skin stapler with 6 mm wide staples. These are readily available in Emergency Departments for wound closure. Use the nondominant hand to appose the wound edges. Grasp the stapler with the dominant hand. Place staples at 5 mm intervals until the wound is closed.

Suture Techniques

Suturing of cardiac wounds is more time consuming than the other methods previously described. It requires technical proficiency and understanding of the heart's surface anatomy. Place horizontal mattress sutures using 2-0 or 3-0 silk or Prolene suture material (Figure 44-7). Do not tie the sutures tightly. It is easy to inadvertently tear through the myocardium. Use teflon pledgets to reinforce the repair and prevent cutting through the heart tissue (Figures 44-7A & B). This is especially important when the wound edges are irregular or tattered. Use care to avoid injury to the coronary vessels, which may lie in close proximity to a cardiac wound. Ensure that the sutures are placed adjacent to and underneath the coronary vessels (Figure 44-7C).

Large cardiac wounds are difficult to repair. They bleed profusely. The digital occlusion and Foley catheter techniques are ineffective on large wounds. The wound edges are difficult to grasp and appose so that they can be repaired with a skin stapler. Place an incomplete horizontal mattress stitch on each side of the wound (Figure 44-8). Grasp the free ends of the sutures and cross them across the wound to appose the wound edges. Instruct an assistant to hold the suture ends while the cardiac wound is repaired with 2-0 or 3-0 silk, Prolene, or staples. The incomplete mattress sutures may then be removed or tied to each other.

Fibrillation

The myocardium can be deliberately placed in fibrillation to halt myocardial contractions and repair large ventricular wounds. This should be performed only if other techniques of cardiac wound repair are unsuccessful. Choose the proper size internal cardiac paddles. The paddle size for an infant is 2 cm, for a child is 4 cm, and for an adolescent or adult is 6 cm. Insert the sterile paddles into the sterile handles (Figure 44-9). Pass the cables exiting the base of the handles to an assistant to insert into the defibrillator machine ports. Instruct the assistant to turn on the defibrillator.

Place the internal cardiac paddles on the anterior and posterior surfaces of the heart (Figure 44-10). While the paddles can be placed directly on the heart, it is recommended by some to place sterile saline-moistened gauze squares between the paddles and the heart to aid in conduction. Apply 20 Joules (J) of energy through the paddles to fibrillate the adolescent or adult heart. Begin with 5 J of energy to fibrillate the infant or child heart. Proceed upward incrementally as required to a maximum of 20 J to fibrillate the infant or child heart. Quickly repair the cardiac wound.

Perform intermittent cardiac massage while repairing the fibrillating myocardium to maintain cardiac output. Do not allow the heart to fibrillate for more than 3 minutes. Defibrillate the heart with the internal paddles using 20 J of energy for the adult and adolescent heart. Repeat the defibrillation with 20 J of energy until the heart begins beating. In general, do not use more than 20 J to defibrillate the adult or adolescent heart with the internal cardiac paddles as myocardial necrosis can occur. It may be occasionally necessary increase the energy in the adolescent or adult to 40 J then 60 J if multiple attempts at 20 J are ineffective. Begin with 5 J of energy to defibrillate the infant or child heart. Proceed upward incrementally as required to a maximum of 20 J to defibrillate the infant or child heart.

If the patient is resuscitated, cover the thoracotomy wound with saline-moistened gauze and a simple dressing. Administer broad spectrum antibiotics if not done previously. Immediately transport the patient to the Operating Room for definitive repair of the cardiac wound and any other injuries by a Trauma or Cardiovascular Surgeon.

The complications associated with digital pressure include further destruction of tissue. If pulled too tightly, Foley catheters can become dislodged and restart troublesome bleeding. They can also enlarge a cardiac wound if the cuff pulls through the wound. A drop in cardiac output can result if the cuff obstructs the cardiac valves, impinges on the chordae tendineae, or occupies too much space within the cardiac chamber. Decrease the cuff size by withdrawing some of the saline from the cuff. Suturing is probably associated with the greatest rate of complications. Tearing of the myocardium is a frequently encountered problem. The suture should be tied just tight enough to stop the bleeding. Care should be exercised to avoid ligation of the major coronary vessels and their branches. Dysrhythmias can result from occlusion of venous inflow (Sauerbruch maneuver) or injury to the coronary vasculature. If the patient is resuscitated, administer broad-spectrum antibiotics to prevent any potential infectious complication.

Injuries to the heart can be devastating. The role of the Emergency Physician is to rapidly and temporarily control bleeding and ensure the transport of the patient to the Operating Room for definitive repair. If there is a delay in transporting the patient to the operating room, the Emergency Physician must be versed in the techniques used to repair cardiac wounds and resuscitate the patient.