The incidence of penetrating cardiac injuries appears to be rising, presumably because of an increase in civilian violence.Herein, a case of right ventricular wound associated with laceration of left internal mammary artery- LIMA- and brachial artery transaction is reported. The management of the case is outlined with literature review. The patient with penetrating cardiac injury should be taken to the operation room as quickly as possible. Rapid transport of patient to operating room and urgent surgery were essential to save this patient.

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By
Professor Abdulsalam Y Taha
Sulaimani Teaching Hospital
School of Medicine
University of Sulaimani
Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

2. INTRODUCTION
The incidence of penetrating cardiac injuries
appears to be rising, presumably because of an
increase in civilian violence.
In 1896, Dr. Ludwig Rehn of Frankfurt, Germany
first successfully sutured a stab wound of the
heart. It was a case of right ventricular wound. He
wrote reporting the case: This proves the
feasibility of cardiac suture repair without a
doubt! I hope this will lead to more investigations
regarding surgery of the heart. This may save
many lives.) But for decades this operation
remained an isolated historic achievement.

3.  Certainly, stab wounds of the heart were common
prior to 1896, but what held surgeons back?
Perhaps it was the belief, held by authorities since
antiquity, that cardiac wounds could not be healed.
 Aristotle wrote:
The heart alone of all the viscera can not withstand
injury. This is expected because when the main so-urce
of strength- the heart- is destroyed, no strength
can be brought to other organs which depend on it.
 In 1882, Block reported creating stab wounds in
rabbits hearts and then repairing them. He suggested
attempts in patients.

4.  Billroth commented on Block s repair of rabbit heart
:wounds
A surgeon who tries to suture heart wounds)
(.deserves to lose the esteem of his colleagues
 Stephen Paget )1896: Surgery of the Chest(:
Surgery of the heart has probably reached the limits
set by nature to all surgery: no new method or
discovery can overcome the natural difficulties that
.(attend a wound of the heart
 Ten years after Rehn initial repair, he accumulated
a series of 124 cases with a mortality of only 60%
.quite a feat at that time

5.  George Fischer published a monograph in 1868
that documented a 10% recovery rate in 452
.cases with heart wounds
The report indicated that heart wounds did not
.necessarily result in certain death
 Herein, a case of right ventricular wound
associated with laceration of left internal
mammary artery- LIMA- and brachial artery
transaction is reported. The management of
.the case is outlined with literature review
Informed consent of the patient is obtained•
.to publish his images

6. CASE HISTORY

7. CASE
• R B
• 35 year old man
• 25th Sept. 2004
• Three hours after
.injury
Two stab wounds:
.Ant. chest & L arm
Chest wound: L 4th
i c space just lateral
to sternum. Profuse
bleeding on leaning
.forwards
Pallor and shock.
Bp= 80/60 mmHg
PR= rapid and feeble.
Heart sounds:
inaudible.
Chest: good air entry
bilaterally.
Neck veins: distended.
L upper limb:
Bleeding controlled
by
dressings.
Ischaemic limb.

8. Normal-sized heart
No haemo- or pneumothorax

10. R V repair: interrupted Dacron-buttressed
.mattress 2-0 silk sutures

12. Lacerated
:LIMA
Controlled
. by ligation

13. Fasciotomy: viable tissues.

18. End to end repair of brachial artery.

25. DISCUSSION

26.  The presented case has a combination of three
potentially fatal injuries. Penetrating cardiac
injury, LIMA laceration and transaction of brachial
artery. Any of these injuries can kill the patient by
exsanguinations. Laceration of LIMA is a common
. associated injury
 The two life- threatening problems after cardiac
. trauma are tamponade and haemorrhage
 Tamponade develops rapidly as the normal
pericardium can accommodate only 100 to 250 ml
.of blood

27.  Small wounds, such as those from a knife, often
produce tamponade because the laceration in the
pericardium is small. Larger wounds, produced by
bullets or larger knives, threaten immediate death
from exsanguinations as blood can be expelled
through the pericardial laceration into the pleural
cavity.
 Generally speaking, tamponade carries a better
prognosis than frank haemorrhage.
The RV, which constitutes most of the anterior
portion of the heart, is the cardiac chamber most
frequently injured.

28.  The patient with penetrating cardiac injury should
be taken to the operation room as quickly as
possible. As stated by Kirklin and Barrat Boyes, no
more than 5 minutes need elapse between
admission and the patients transfer to the
operating table.
 A median sternotomy is the preferred incision, as
it provides ready access to all chambers of the
heart.

29.  In this case, the external bleeding arose from both
lacerated LIMA and . ventricular wound
 Cardiac tamponade resulted from clots sealing the
.pericardial defect
 The site of stab wound( left 4th inter-costal space)
together with triad of hypotension, distended neck
veins and inaudible heart sounds were highly
.indicative of tamponade
 Rapid transport of patient to operating room and
.urgent surgery were essential to save this patient
 The R coronary artery was fortunately not involved
.by the wound

30. The standard technique was used in repair.
Air embolism was prevented by digital sealing
.of the wound
No sign of myocardial ischaemia occurred.
The lacerated LIMA was treated next to
ventricular wound.
The peripheral arterial injury was the last to be
considered in this patient whose life salvage
took the priority over limb salvage.
However, arterial repair was done as
meticulously as we used to do in isolated arterial
injuries. Fasciotomy was detrimental to his limb
salvage.