Deals with the modern concept of management of penetrating cardiac injuries and the dilemma involved with pericardial window and pericardiocentesis

1. Cardiac Injuries
Presenter- Dr Sushant Soren
Moderator- Dr Dinesh Bagaria

2. History
• Dates back to 3000 BC
• Until the late 19th century, the commonly held belief
agreed with Boerhaave’s sentiments that, “all
penetrating cardiac trauma is fatal.”
• Theodore Billroth warned, “The surgeon who should
attempt to suture a wound of the heart would lose
the respect of his colleagues.”

3. • Paget believed that
“Surgery of the heart has probably reached the limits
set by nature to all surgery: no new method of
discovery can overcome the natural difficulties that
attend a wound of the heart.”

4. • Around the time of World War II, it was recognized
that cardiac tamponade could be successfully
managed by pericardiocentesis
• With the advent of cardiopulmonary bypass by
Gibbon in 1953, repair of more complex injuries
became possible.

5. Incidence
• Penetrating> blunt
• Penetrating injuries carry higher mortality rates
• 1198 patients in South Africa, 6% reaches hospital
with signs of life
• 25% of MVI deaths are due to thoracic trauma; out
of which 10-70% are due to cardiac injuries

10. Our experience

14. This data was further extrapolated for
5 more years

16. ASSOCIATED INJURIES NUMBER (35/46)
Thoracic injuries 24
Abdominal injuries 14
Diaphragmatic injury 2
Head injury 2
Long bone fracture 6
Results (n=46)

17. CARDIAC INJURIES
BLUNT CARDIAC
INJURY
PENETRATING
INJURY
Rt Atrium 4 7
Rt Ventricle 6 7
Left Ventricle 2 7
> 1 chamber 1 (RA+RV) 2 (RV+LV)
With vascular
injury
3 3
Myocardial
contusion
4 -
Results (n=46)

18. Results (n=46)
Average
(days)
<5 days <10 days <15 days
ICU stay 10.8 10 13 15
Hospital
stay
21.4 - 7 10

19. Mortality (n=13/46)
• Mean ISS - 38.6
• HR >100 – 10
• SBP <90 -8
• FAST+ve - 11
• CT - 8
• Pericardiocentesis -2

20. Case scenario

21. Demographic profile
• 25/M
• Brought By Relative
• Resident Of Tughlakabad Gaon
• Time of injury- 1830 hrs
• Time Of Presentation- 1950 Hrs
Mechanism
Self inflicted wound chest with sharp object of size
3x2 cm just left to mid-sternum.

22. Primary survey
AIRWAY - Patent, c-spine stabilized
BREATHING - Spontaneous, RR-25/min,spo2-98%;
CIRCULATION - Pulse- 116/min, BP-80/56 mmHg

23. What next?

24. • High flow 02
• 1 litre of warm crystalloid
• MTP initiated
• OT intimation given

25. FAST
Sensitivity- 100%
Specificity- 97.3%

27. Cardiac tamponade

28. • As blood accumulates there is decreased ventricular
filling leading to decreased stroke volume
• A compensatory tachycardia ensues and elevated
right heart filling pressures
• 60- 100 ml
• Rate of bleeding is more in ventricles so early
tamponade

29. • Becks triad
• Pulsus paradoxus Unreliable signs
• Kussmaul’s sign
• Narrowing of pulse pressure- reliable/measurable

30. What next?
• Pericardiocentesis????
• Open pericardial window???
• OT????

31. Pericardiocentesis
• Causes more injury than doing help
• Was used for diagnosis and decompression
• In our centre we have used it in few cases due to logistic
issues (temporary measure)
• Indications
– Iatrogenic injuries during cardiac catheterisation
– When surgeon is unavailable

33. Open Pericardial Window

34. Open pericardial window(OPW)
• It’s a diagnosing procedure for blood in pericardium
• It can be falsely positive as hemothorax can be confused with
blood in pericardium
• Or can be negetive if the blood has already drained in pleural
cavity
• Recent trends suggest there is almost no diagnostic indication
of OPW

37. •Sample size
too small
•Long term
follow up not
mentioned

39. •lack of follow-up echocardiography
•loss of 9 patients in the drainage-only group to followup
•the undetermined cause of death of a patient in the
drainage only group at 10 months post surgery.

40. • “For the millennial readers, seeking instantaneous gratification, I
could complete this editorial with one word - “NEITHER”! The
surgeon, presented with a dying patient following thoracic trauma,
needs to know the correct approach for the best functional outcome
is – immediate left anteroateral thoracotomy through standard
techniques.”
• The clotted blood cant be drained by pericardiocentesis effectively,
though OPW helps in draining, its of no definitive help

41. What next?
• Shift to OT

42. Surgical approach

43. Clamshell thoracotomy
• Sternotomy- posterior
mediastinum & cross
clamping cant be done
• Aortic cross clamping
distal to left subclavian if
necessary

45. Sternotomy vs Clamshell thoracotomy
Sternotomy
Excellent approach to ant. mediastinum
Technically difficult
More post op complications
B/l chest exploration is difficult

46. • The superior and
intrapericardial part of
the IVC may be cross
clamped when the
hemorrhage is so
severe that the surgeon
is unable to visualise
the source
• This inflow occlusion
may be maintained for
2–3 min, but then the
heart will stop

47. Intra op
• There was 2.5 cm incised wound in the left parasternal area
in 6th intercostal space.
• There was about 300-350ml of blood in the pericardium
• Stab injury in the Rt ventricle about 1.5 x0.3cm in size with
active
bleeding from the injury site.
Operative procedure
• Clamshell thoracotomy done
• Pericardium opened , blood drained
• Stab injury in the rt ventricle

48. Surgical anatomy

49. Penetrating cardiac injuries
• Right & left ventricles are at greater risk
• In a study of 711 patients
• 54%- stab
• 42%- gunshot
• RV- 40%
• LV- 40%
• RA- 24%
• LA- 24%

50. • Leaking pericardium gives time
• Fluids, Blood& ICD should be inserted
• 80% of the stabs eventually lead to tamponade as
rapid bleeding favours clot formation
• Sealed pericardium leads to tamponade which
mandates urgent decompression

51. • Foreign bodies can be left in situ
• small, right sided
• Embedded to wall
• Fibrous covering
• Sterile or asymptomatic
• Right sided embolise to PA-> removed via catheter
• Left sided manifest as systemic embolisation

52. Cardiorrhaphy
• Poor technique
• Enlargement of lacerations
• Injury to coronary vessels
• 30% needle stick injuries
• Temporarising measures
• Digital pressure
• Foley inflation
• Staplers use

53. A. finger occlusion
B. partial occluding
clamps
C. foley inflation
D. skin staplers

54. On table cardiac arrest
Indicators
– PEA(Vt,vf, Bradycardia, Asystole)
– "Loss" of the intra-arterial pressure waveform
– Sudden fall in spo2
– Loss of etco2

55. • What to do then?
• Cardiac massage( 60% of stroke volume, 2-3 mins)
• Defibrillation- VF or pulseless VT
• Start with 10 joules, can be taken upto 50 joules
• Epinephrine every 3-5 mins
• Intracardiac only if there is no IV access
• Even after 3 shocks, rhythm is shockable
amiodarone is administered

58. Lower survival in
– Delay > 2 mins in starting massage
– Use of defibrillators
– Use of epinephrine

59. Pregnant patients
• left lateral uterine displacement is necessary if
fundal height is at or above the umbilicus
• in order to minimize aortocaval compression
• optimize venous return (preload)
• generate adequate stroke volume during CPR

60. Good massage?
• diastolic blood pressure (BP) between 30 to 40
mmHg have a higher chance of successful ROSC
• sudden increase in EtCO2 to 35 to 40 mmHg
indicates ROSC.
• presence of an arterial waveform, palpable carotid
or femoral pulse, and/or by obtaining a
noninvasive BP cuff measurement
• EtCO2 readings >20 mmHg during CPR are
associated with better outcome and survival,
while EtCO2 readings <10 mmHg for 20 minutes
are associated with failure of ROSC

62. • Abrupt manipulation and elevation of the heart can result
in dysrhythmias and cardiac arrest
• It may be useful to pour saline warmed to 40° C over the
heart
• Additionally, partial elevation by inserting a folded
laparotomy pad between the posterior aspect of the heart
and the posterior pericardium may allow the heart time to
adapt to the elevation

63. What else can be done

64. Epicardial retracting
stabilizer
• The lateral aspects of the
ventricles and areas
adjacent to the LAD
artery
• This device is attached to
the sternal retractor, and
the footplates are
positioned parallel to or
at a 90° angle to the
injury, thus
approximating the edges
and stabilizing the heart

66. Post operative management
• Continuous cardiac ECG monitoring
• 3rd and 7th post surgery day for ECHO
• In case of presence of murmurs in immediate post op
period urgent ECHO to rule out valvular, septal and
chordae injury
• No role of biomarkers in post op period
• Because incidence of late sequelae are 56% follow up
ECHO at 3-4 weeks is recommended

67. Blunt Cardiac Injuries

68. Introduction
• BCI (20% to 76%)
• Right > Left
• Venticles = Atrium
• M.C. "Cardiac contusion"
• Arrhythmia, RWMA, progressing to cardiogenic
shock
• Rupture of valves/ septum, or chamber walls
(complex)

70. Echocardiography

71. Association & sternal fracture
• An eight-year review of the united states national trauma
data bank involving over 15,000 patients with BCI, the
finding most strongly associated with BCI was
hemopericardium (odds ratio [OR] 9.58), which was
almost twice as likely as either sternal fracture or
thoracic aortic injury
• In one autopsy series of patients who died following a
fall from a height, sternal fractures were found in 76
percent of cases involving cardiac injury, whereas only 18
percent of cases had a sternal fracture without
associated cardiac injury

73. Interesting cases

74. •A 5-year-old, 20 kg male presented with a single pellet gunshot wound
to the left thorax, just lateral and inferior to the left nipple, with no
corresponding exit wound.
•CXR- round ballistic adjacent to cardiac silhoute
•CTA- metallic pellet injury with an injury tract extending from the left
anterior chest wall through the anterior left upper lobe adjacent to the
apex of the left ventricle (LV) with the ballistic adjacent to the right
atrium, as well as a moderate sized hemopericardium
•ECHO- A moderate pericardial effusion with possible right atrial and
right ventricular buckling without mitral valve inflow abnormalities

75. • SX- Median sternotomy, repair of left ventricle(7-
0 prolene), left anterior descending coronary and
cephalad to a diagonal branch after evacuation of
pericardial hematoma .
• C- ARM- Projectile inferior to the diaphragm and
posteriorly located, suggesting embolization to
the inferior vena cava
• POST OP CTA- Projectile in the right renal vein.

77. Hypothesis Of Migration
 Through defect in ventricular septum, then
retrograde embolisation
 Through RV to LA
 Through the posterior aspect of the left AV
groove into the coronary sinus with subsequent
drainage to the RA

79. • 46/m
• single gunshot wound to the left lower
quadrant of the abdomen
• Primary survery
Responder
Left hemothorax- ICD inserted(500 ml)
• Secondary survey- peritonitis
• Taken to OR
Multiple bowel perforations
Left diaphragmatic rupture near to central
tendon

81. • A subxiphoid pericardial window (SPW) was performed
in which a small amount of pericardial blood and clot
was noted
• Subsequent pericardial irrigation via red rubber
catheter was clear
• The pericardiotomy was left open and a damage
control approach with temporary abdominal closure
was performed

82. • Postoperative CECT
revealed the bullet
lodged between the
left pulmonary hilum
and pericardium,
without evidence of
cardiac injury

83. • POD 2
The patient returned to the operating room for
bowel anastomoses and abdominal closure
• POD 5
VATS for evacuation of retained hemothorax and
the bullet tract was noted to terminate in the left
pulmonary hilum, without evidence of cardiac
injury, pericardial violation, pulmonary
hemorrhage, or air leak.
• POD 17
Discharged

84. • Eleven months later, he returned desiring repair of a
ventral incisional hernia
• During evaluation, he reported 2 months of symptoms
consistent with recurrent syncopal events.
• A transthoracic echocardiogram and CT angiogram of
the chest were obtained to interrogate for
cardiovascular complications associated with the
retained hilar bullet, which demonstrated a 5.5 * 3.4
cm left ventricular pseudoaneurysm with a 5-mm neck

86. • A median sternotomy approach with cardiopulmonary
bypass
• The pericardium was carefully dissected, the left
ventricular pseudoaneurysm sac was excised, and a
bolstered primary repair was performed with
pledgeted sutures

88. From our experience
• Expedited transfer to the OT enhances chances of
survival
• Penetrating injury may not present with cardiac
tamponade
• Atrial injury is best repaired, post vascular clamp
• Ventricle injury is best repaired with digital pressure
/ skin staples followed by sutures
• Minimal handling of the heart reduces the possibility
of arrythmias

89. Recommendations
• Surgeon performed USG aids in early recognition of TCI
• All patients with penetrating cardiac injuries must be
explored
• Clamshell thoracotomy with pericardotomy is preferred
approach
• A thorough search for associated injuries must be
sought

90. “ The road to the heart is only 2-3 cm, in a
direct line, but it has taken surgery nearly
2400 years to travel it”
- Harry Sherman, 1902

91. Thank you!