History of cardiac trauma surgery
A J Nicol, MB ChB, FCS (SA), PhD; P H Navsaria, MB ChB, FCS (SA), MMed (Surg); D Kahn, MB ChB, FCS (SA), ChM
Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa
Corresponding author: A Nicol ([email protected])
The ancient Egyptians, although realising the diaphragm, of the small intestine, of the coronary artery and that blood in the the anatomical importance of the heart, stomach and of the liver is deadly.’[8,9] Aristotle pericardial sac could compress the heart and were largely responsible for the aura of (384 - 322 BC) wrote that ‘The heart again restrict its movement.[17] mysticism and superstition that enveloped is the only one of the viscera, and indeed the heart for centuries. The Egyptian Book the only part of the body, that is unable to The nihilism surrounding cardiac injuries of the Dead (c. 1567 BC) describes how, on tolerate any serious affection. This is but what continued and in 1804 John Bell published entry to the underworld, the jackal-headed might reasonably be expected. For, if the his Discourses of Nature and Care of Wounds, Anubis weighed the heart of the deceased primary or dominant part be diseased, there declaring that ‘there is so little to be done … against a statue of the goddess of truth and is nothing from which the other parts which and the signs and consequences are so clear, justice.[1,2] If the heart weighed the same, the depend upon it can derive sucour’.[10,11] Celsus that it is a waste of time to speak longer of dead person was admitted ‘to the company (1st century AD) recognised the clinical wounds of the heart’.[5,18] of Osiris and the blessed; if not, if his heart features of shock associated with a cardiac was heavy and laden with sin, it was cast to injury when he wrote in De Medicina that, There is dispute over who should be named the devouring beast Ammit’.[3] ‘When the heart is wounded much blood as the first modern cardiac surgeon. The two is lost, the pulse weakens, pallor becomes contenders are the extremely well-known extreme, a cold and foul sweat arises from the Baron Larrey and the almost unheard of Hippocrates recognised stricked body, the extremities become cold Catalonian surgeon called Francisco Romero. [9,12] that cardiac injuries were and speedy death follows’. Pliny the Elder These two men apparently performed the first (AD 23 - 79) felt that the heart ‘is the only open pericardiotomy at approximately the invariably fatal. one among the viscera that is not affected same time. Francisco Romero of Barcelona by maladies, nor is it subject to the ordinary performed an open pericardiotomy on a penalties of human life; but when injured, it patient with a pericardial effusion around Homer was the first author to narrate a produces instant death’.[9,13] 1810. He presented his memoir, Observatio cardiac injury in the Iliad (c. 950 BC), when experimentis confirmata, pro hydrope pectori, the Greek commander, Idomeneus, killed Claudius Galen (AD 130 - 200) expressed pulmonum anasarca, et hydropericardio the Trojan, Alkathoos.[4] his sentiment of the hopelessness of a cognoscendis; et nova methodus dittos morbos ‘Idomeneus smote him with a thrust of his cardiac wound: operandi, to the Society of the School of spear full upon the breast, and clave his 'When a perforation penetrated in one of Medicine in Paris in 1815. An incision was coat of bronze around him, that aforetime the cardiac ventricles, they (the gladiators) made over the costal cartilage of the 6th rib ever warded death from his body, but died on the spot, mainly by blood loss, and and after opening up the pericardial sac the now it rang harshly as it was cloven about even faster if the left ventricle was injured. fluid was allowed to drain into the pleural the spear. And he fell with a thud, and When the penetrating object did not pass space. These open surgical procedures were the spear was fixed in his heart, that still through the cardiac cavity but stopped at viewed at the time as being unnecessarily beating made the butt thereof to quiver.’ the cardiac muscle, some of the wounded aggressive and the Society did not endorse gladiators lived through the very day on his ideas.[19] TheIliad and the Odyssey contain numerous which they were wounded as well as the references to cardiac injuries.[5-7] Achilles’ following night; they eventually died later best friend, Patroclus, killed Sarpedon, the because of an inflammation.’[3] There is dispute over son of Zeus, with a spear to the heart. ‘The prostrate prince, and on his bosom The teaching of Hippocrates, Aristotle and who should be named as trod; Then drew the weapon from his Galen that all heart wounds were fatal was the first modern cardiac panting heart, The reeking fibers clinging followed until, in 1604, Cabriolanus found surgeon. to the dart; From the wide wound gush’d healed scar tissue in the hearts of individuals out a stream of blood, And the soul issued who had died by hanging.[14,15] The idea that in the purple flood.’ not all cardiac wounds were fatal was also Baron Dominique Jean Larrey, the suggested by Holerius.[9,16] Surgeon-in-Chief of Napoleon’s imperial Hippocrates recognised that cardiac injuries guard, made a number of contributions were invariably fatal. ‘A severe wound of Morgagni (1761) was the first to recognise to trauma surgery. He invented the ‘flying the bladder, of the brain, of the heart, of cardiac tamponade from an injury of the ambulance’ to rescue the wounded from the
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scene of battle. Previously, casualties were and other madness.’[21] He also remarked that Farina of Rome sutured the right ventricle considered to be a nuisance. He introduced ‘A surgeon who tries to suture a heart wound in a 30-year-old man who had been a system of triage to manage patients deserves to lose the esteem of his colleagues’.[22-24] stabbed in the left chest with a fi ne dagger according to the severity of their wounds In 1896 Paget wrote that ‘Th e surgery of the at the Spedale della Consolazione in March and also successfully decompressed the heart has probably reached the limits set by 1896. Th e 5th costal cartilage and rib were pericardial sac of a patient by catheter nature to all surgery; no new method and removed and fi ve silk sutures were placed drainage. Th e pericardiotomy that was no new discovery can overcome the natural into a 7-mm wound of the myocardium. performed by Baron Larrey was conducted diffi culties that attend a wound of the heart. On the 8th postoperative day the patient on Bernard Saint-Ogne, a 30-year-old It is true that heart suture has been vaguely died from a bronchopneumonia, but at infantryman who had attempted suicide proposed as a possible procedure and has autopsy the heart was found to be perfectly by stabbing himself in the chest aft er been done on animals, but I cannot fi nd that healed.[31,32] being accused of an off ence that he did not it has ever been attempted in practice.’[25] commit, on 18 March 1810.[20] Th e fi rst successful cardiac repair was performed by Dr Ludwig Rehn of Frankfurt ‘In the left side of the chest, the pericardium Between 1912 and 1914 on 9 September 1896. [33] A 22-year-old man, and the left lung were wounded, the knife Wilhelm Justus, was brought to the hospital passed through the fi ft h costal cartilage and there were more than in a state of collapse aft er sustaining a was still in the wound when he was brought 75 cardiac operations penetrating wound in the fourth interspace. into hospital. Frothy blood escaped in jets and the mortality Stimulants were administered, which was with each systole. Th e knife was withdrawn followed by improvement, but 24 hours later and the wound dressed with plaster; the rate appeared to be his condition was so much worse that the patient tore off the dressing and it was diminishing, with an patient was operated upon. Ether was used reapplied. Th e pulse was rapid and there was overall rate of around for narcosis.[34] A resection of the 5th left rib grave dyspnoea. Bleeding gave some relief. was undertaken and the pleura was cleared Some improvement took place, but later 45%. of blood. Dr Rehn describes the operation on he became worse, and in great distress further: ‘Th ere is continuous bleeding from requested Larrey either to open his chest or a hole in the pericardium. Th is opening is to give him a narcotic strong enough to send However, there was about to be a radical enlarged. Th e heart is exposed. Old blood him to sleep. Operation 45 days aft er injury, shift to surgical management. In 1876 and clots are emptied. Th ere is a 1.5 cm incision through the skin and cellular tissue Gottard Bulau of Hamburg developed gaping right ventricular wound. Bleeding is in the fi ft h space below the nipple, carefully the system of the underwater drainage controlled with fi nger pressure ... I decided carried deeper until pericardium felt. With of the pleural cavity. Th is was a huge to suture the heart wound. I used a small the left index fi nger on the pericardium as a milestone in the progress of managing guide an incision into the pericardium was penetrating chest trauma and overcoming made with a bistoury, the fi nger inserted, the inherent problem of the associated and the apex of the heart felt. About a liter haemopneumothorax and allowing for of fl uid with some blood clot escaped. Great re-expansion of the lung. De Vecchio relief. In ten days the wound closed and the demonstrated the feasibility of cardiac symptoms recurred. Wound reopened with repair in dogs by showing a healed wound a probe, 4 oz of pus escaped. Considerable in the heart of a dog to the Eleventh improvement. Death 68 days aft er injury and International Medical Congress in Rome 23 aft er the operation. Autopsy: suppurative in 1895.[26] Ansel Cappelan of Norway mediastino-pericarditis.’[14] then performed the fi rst suture of the human heart in 1895.[27] Th e patient was Despite the advent of these open surgical a 24-year-old male who had been stabbed approaches, the management of cardiac in the left chest in the 4th intercostal space injuries in the beginning of the 19th century and had presented with symptoms of consisted of venesection, leeches, absolute cardiac tamponade. He was anaesthetised quiet and an attempt to evacuate fl uid by with chloroform and a 4th and 5th rib passing a sound into the wound. In 1875 resection was performed, showing that the Billroth condemned both pericardiocentesis pericardium was distended with blood. Th is and any surgical attempts at repairing was opened and a 2-cm injury to the left the wounded heart. ‘Paracentesis of the ventricle was sutured with chromic catgut pericardium is an operation which, in my and the left anterior descending coronary opinion, approaches very closely to that artery was ligated. Th e patient died 2 days kind of intervention which some surgeons later from what was considered to be a would term a prostitution of the surgical art pericarditis and anaemia.[9,28-30] Dr Guido
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intestinal needle and silk suture. Th e suture Duval described the median sternotomy pressure, at rates up to 1.5 litre per minute. was tied in diastole. Bleeding diminished in 1897 and much of the French success Penicillin, which was just beginning to remarkably with the third suture, all in dealing with thoracic injuries during make an impact on thoracic surgery, was bleeding was controlled.’ the great war was due to this technique.[36] oft en given in 10 000 unit injections’.[11,42] A number of extraplural approaches to the Th e postoperative period was complicated heart were developed because entry into the Cardiac tamponade was noted by Paul by a pneumothorax and chronic infection pleural cavity had to be avoided. Samson, an American surgeon based at but the patient made a complete recovery a forward hospital during World War and returned to work.[11,35] Walter Kirchner, a surgeon from St Louis, II, to be an unusual presentation in war successfully repaired a stab to the left wounds, in stark contrast to civilian ventricle using an extrapleural approach cardiac injuries, as the missiles were larger via a left sternal flap. He reported to the and the wide pericardial tears allowed The fi rst successful Southern Surgical and Gynecological for drainage of the pericardial sac into cardiac repair was Association in 1909 that ‘one must be the chest.[43] World War II saw a step back convinced that injuries to the heart can no towards conservative management of cardiac performed by Dr Ludwig longer be considered as invariably fatal, wounds. Th is was due to the perception of Rehn of Frankfurt in but that the heart may be manipulated a high mortality associated with cardiac September 1896. and treated surgically just as any organ repair (between 25% and 30%) and the of the body’.[37] In 1909 Charles H Peck fact that a number of selected patients of New York reported the successful recovered without operative intervention. suture of an injury to the right auricle An era of conservatism returned to the In his address to the German Society in a 24-year-old girl. She presented with surgical management.[44,45] Dr Alfred of Surgery, Rehn said ‘the feasibility of cardiac tamponade, her pulse returning Blalock introduced pericardiocentesis as cardiorrhaphy no longer remains in doubt after the pericardial sac was excised and the defi nitive treatment for cardiac wounds ... I trust that this case will not remain 300 cc of blood evacuated. He tabulated presenting with tamponade. In 1943 Blalock a curiosity, but rather, that the field of 161 cases of primary suture of the heart and Ravitch described the survival of 3 out cardiac surgery will be further investigated. in the medical literature from America, of 4 patients treated conservatively.[46] In Let me speak once my conviction that by France, Germany, Spain, Italy, Canada 1949 they reported the survival of 7 patients means of cardiorrhaphy, many lives can and England. No previous surgeon had with cardiac tamponade with aspiration of be saved that were previously counted as reported more than 3 cases. The overall the pericardial sac.[47] Blau in 1945 reported lost’.[3,35] operative mortality of sutured heart 27 cases of penetrating cardiac injuries. wounds was in the order of 64%.[38] Th e mortality rate of 17% achieved with aspiration alone compared favourably with Brewster in 1911 defi ned the term cardiac the operative intervention rate of 24%.[48] tamponade ‘as the haemorrhage increases, Th e majority of surgeons adhered to this the pericardial opening sometimes becomes conservative view, operating only when there occluded and the condition known as was external haemorrhage into the thoracic cardiac tamponade arises’.[39] Luxembourg or peritoneal cavity, when there was failure emphasised the clinical feature of cardiac of pericardiocentesis to relieve symptoms, tamponade – a patient with symptoms of or when the tamponade recurred. Th ere air hunger, shortness of breath and pain will was, however, a small body of surgeons that obtain relief by adopting a sitting posture.[40] maintained that there should be immediate Between 1912 and 1914 there were more than surgical intervention in these injuries 75 cardiac operations and the mortality rate regardless of the circumstances.[49-51] appeared to be diminishing, with an overall rate of around 45%. In 1951 Elkin from Atlanta, Georgia, was still recommending a trial of aspiration A United States surgeon based in London, of the pericardial sac in all cases of Dr Dwight Harken, removed 134 missiles cardiac injury while the operating room from the mediastinum, including 13 from was being prepared. In selected cases the heart, during World War II without any careful observation would be continued mortality.[41] He wrote of his experience: if the patient responded positively to the ‘To remove the missile, the heart was oft en pericardiocentesis. Th ey managed 18 split wide open, with tremendous blood patients with stab wounds to the heart loss. Rapid, massive, blood transfusions with this protocol and surgery was only were needed to keep the patient alive. undertaken in one patient. Of the 17 patients Whole blood was oft en administered, under treated conservatively there was one death, a
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mortality rate of 6%.[45] Cooley et al. in 1955 ‘trial of therapy’ was starting to be adopted taken to thoracotomy with or without wrote that they were in complete agreement by a number of centres. However, several pericardiocentesis. Th ey attributed this with Ravitch, Blalock and Elkin in their series then showed that the outcome of drop in mortality to more rapid triage with recommendation that the initial treatment patients was poor if they had undergone the development of a trauma service and of a penetrating injury to the heart should cardiac repair only aft er responding poorly an increased interest in traumatic injuries. be non-operative and that attempted cardiac to pericardiocentesis.[56] Th is is indicative of the dramatic shift in the repair should be reserved for those patients management of penetrating cardiac trauma that do not respond.[52] from pericardiocentesis to operative In the early 1950s a intervention.[54] Symbas et al. compared In the early 1950s a patient was seldom the management of their penetrating operated upon in most centres until patient was seldom cardiac injuries between 1964 and 1974 and there had been several attempts made at operated upon in found that the mortality rate for patients pericardiocentesis.[53] Towards the end of the most centres until presenting with cardiac tamponade was 5% decade there was an increasing tendency to in patients operated on immediately versus early thoracotomy in unstable patients aft er there had been several 17.5% in patients managed initially with a single aspiration of the pericardial sac. Th is attempts made at pericardiocentesis and where surgery was move towards early operation may well be pericardiocentesis. reserved for patients who did not respond attributed to the advent of cardiac surgery or where the tamponade recurred.[57] and the beginnings of the development of a trauma service in the USA. Th is shift from conservative to surgical A number of studies in the 1960s stressed management is beautifully illustrated in In the 1960s mandatory surgical exploration the danger of a delay in cardiac surgery. the three papers published from Baylor versus conservative management with In Wilson’s study the patients operated University (1955, 1966 and 1972). Th e pericardiocentesis remained a controversial on within 30 minutes had a mortality of mortality from stab wounds to the heart issue.[54] In 1966 in the Journal of the American 10% versus 26% in those who had surgery decreased from 22% to 13%.[3,51] By the 1970s Medical Association, Wilson reviewed 200 later. Beall et al. reported a dramatic the continued advances in cardiovascular penetrating wounds of the pericardium increase in mortality from 27% to 63% surgery and presence of trained personnel, from Wayne State University College of if pericardiocentesis failed to relieve a combined with the reduction in mortality, Medicine in Detroit and concluded that tamponade and surgical intervention was resulted in immediate cardiorrhaphy cardiac repair should be performed rapidly delayed.[53,57] In 1968 Yao et al. published becoming the universal treatment of choice.[58] on all patients except those who maintain their series of 80 penetrating cardiac normal vital signs aft er pericardiocentesis. injuries. Th ey had managed cardiac injuries References available at www.cmej.org.za In their series, 9 patients out of the 200 from 1959 to 1965 with pericardiocentesis. (4.5%) had suffi cient improvement aft er If the patient responded then nothing pericardiocentesis to avoid any further else was done. Only when there was no surgery. One of these 9 patients died.[55] clinical response to pericardiocentesis or Th e majority of surgeons were convinced recurrent accumulation was a thoracotomy at this time that the best form of therapy undertaken. Th is management protocol for severe haemorrhage from a cardiac changed dramatically aft er 1965 when wound was cardiorrhaphy, but doubt still all patients with the diagnosis of stab remained about the management of cardiac wound to the heart were managed with tamponade. Many felt that those patients an emergency thoracotomy. Nineteen with the diagnosis of what was termed out of their 80 patients died (24%) and a ‘pure’ tamponade could be reasonably this mortality dropped to 5% between managed with pericardiocentesis alone. A 1965 and 1967 when all patients were
In a nutshell
• Th e ancient Egyptians were largely responsible for the myth and superstition surrounding the heart. • It was not until the late 19th century that cardiac surgery was recognised as an acceptable approach to cardiac injury. • A shift in management from conservative to surgery occurred with the advances in cardio- thoracic surgery and the presence of trained surgeons.
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