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Penetrating Cardiac Injuries. Complex Injuries and Difficult Challenges

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Penetrating Cardiac Injuries. Complex Injuries and Difficult Challenges TJTES Ulus Travma Derg. 2003 Jan;9(1):1-16 TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY PENETRATING CARDIAC INJURIES. COMPLEX INJURIES AND DIFFICULT CHALLENGES Juan A. ASENSIO, MD FACS, Patrizio PETRONE, MD, Tamer KARfiIDA⁄, MD, J. Ricardo Ramos-KELLY, MD, Sinan DEM‹RAY, MD, Gustavo ROLDAN, MD, Rattaplee PAK-ART, MD, Eric KUNCIR, MD FACS INTRODUCTION Hippocrates (5), stated that all wounds of the The heart is a unique organ, vital and constant heart were deadly. Ovid, Celsus, Pliny, Aristotle, it’s tireless function, working 24 hours a day during and Galen (6-10) regarded all cardiac wounds as the entire life time of an individual. It has inspired fatal. Paulus Aegineta (11) described the venting of many talented poets, writers and musicians the pericardial tamponade. Fallopius (12) throughout the ages. The first description of a described the difference between wounds of the cardiac injury is found is Homer’s poetic right and left ventricles. None other Ambrose Pare description of the death of Sarpedon from the (13) described the presenting signs for cardiac classical Greek epic The Iliad (1,2). injuries. Similarly, Pare (14) also described in his Cardiac injuries remain amongst the most classic masterpiece the Apologie and Treatise, the challenging of all injuries seen in the field of prognosis of cardiac wounds. He described trauma surgery. Their management often requires autopsy results of patients sustaining injuries to immediate surgical intervention, excellent surgical the heart (15). Fabricius (16) and Boerhaave (17) technique and the ability to provide excellent also wrote extensively describing the futility of the surgical critical care to these patients management of these injuries. postoperatively. However, in the 17th Century, the stronghold of these firmly entrenched concepts was broken by HISTORICAL PERSPECTIVE Hollerius (18), a French surgeon who was first to Cardiac injuries have been well described advance the idea that wounds of the heart can throughout the times. The history of the heal and are not all necessary fatal. Wolf (19) in management of these injuries is fascinating. 1642, described a healed wound to the heart. His However, it would take a separate paper to just observation remained forgotten for over a century detail the history. The earliest description of until Senac (20) arrived at the same conclusion. cardiac injuries appear in the Iliad (1,2) which Morgagni (21) in 1761 described the effects of contains specific references to exsanguination as a compression to the heart due to hemorrhage into cause of death and weapons piercing the heart. the pericardium. Larrey (22) in 1810 was first to Other earlier descriptions of penetrating chest describe the approach and surgical technique to wounds can be found in the Edwin Smith Papyrus deal with a pericardial effusion. In 1829 Larrey (23) (3) written around 3,000 BC. described a case of a wound of the pericardium in Beck (4) classifies the history of cardiac injuries patient that recovered which he treated by according to three historical periods. First, the passing a catheter into the stab wound of the period of mysticism, in which wounds of the heart chest. were described but were considered to be Dupuytren (24) was a strong advocate of uniformly fatal. This period extended into the 17th venisection to deal with cardiac injuries. Jobert century. This is followed by the period of (25) in 1839 observed that the life span of a cardiac observation and experimentation, culminating in wound is related to the amount of blood contained the period of suture, which had its beginnings in in the pericardium. With this observation, the 1882. It is in this period that definitive repair and advocated passage of sounds and catheters to many of the current surgical techniques of we know evacuate blood from the pericardium. During this today were developed. period of time, numerous case reports began to 1 2 ULUSAL TRAVMA DERG‹S‹ January - Ocak 2003 appear in the literature, as well as the first attempted the unsuccessful repair of a left attempts to collect these cases. For the first time ventricular stab wound. The first successful authors studied the presentation of cardiac attempt is credited to Rehn (39) of Frankfurt, injuries and reviewed post-mortem studies. Germany, who also in 1896 successfully repaired a Purple (26) in 1850 compiled a total of 42 cases. wound of the right ventricle resulting in the Fischer (27) in 1868 collected 452 cases and patient’s survival. From this moment on the era of reported a 10% survival rate from the literature. cardiac surgery was born. During this period of time no less a prominent Other important contributions to this field were figure in the european surgical stage than Billroth made by Duval (40), who in 1897 described the (28) expressed strong disagreement with any median sternotomy incision. The ingenuity surgeon attempting to repair cardiac injuries. In needed to overcome the surgical inabilities in 1875 he made his strong views well known to the draining and restoring negative intrathoracic surgical world "Paracentesis of the pericardium is pressure after opening the chest resulted in the an operation which, in my opinion, approaches development of different surgical approaches to very closely to the kind of intervention which some the heart. This included the quadrangular flap with surgeons would term a prostitution of the surgical an external hinge, which included two of five act and other madness." Billroth (29), for reasons cartilages developed in 1900 by Fontan (41). Hill unknown continued to proclaim his opposition to (42), an american surgeon was the first to cardiac injury repair. In 1883 he pronounced at a successfully repair a stab wound to the left surgical meeting "the surgeon who should attempt ventricle in 1902. Dalton (43) and Williams44 in to suture a wound of the heart would lose the 1895 and 1897 respectively reported pericardial respect of his colleagues." Furthermore, another operations. Spangaro (45) an italian surgeon statement attributed to him is "let no man dare to described in 1906 the left anterolateral operate upon the heart (28). It is not known why a thoracotomy. While Sauerbruch (46) in 1907 man of his stature in the surgical field would be so described a technique for controlling hemorrhage adamant against this life saving intervention from wounds of the heart by obstructing flow of (30,31). blood that compression of his bace. However, other surgeons emerged to challenge Matas (47) described the dangers of rapidly Billroth. Roberts (32) in 1881 suggested the relieving a pericardial tamponade, which could possibility that cardiac injuries could be sutured result in exsanguinating hemorrhage. Peck (48) in but did not attempt to do so. The period of suture 1909 described a series of cardiac injuries had its beginnings in the animal experiments by collected from the literature and also described Block (33), who in 1882 utilizing a rabbit model, many of the surgical techniques of cardiorrhaphy created cardiac wounds and was successful in that are still widely used today. Pool (49) in 1912 repairing them, thus demonstrating successful also collected additional cases and his own series recovery of the animals and suggesting that the and fully described surgical techniques in the same techniques could applicable in humans. management of cardiac injuries concluding that; Nevertheless, other surgeons continued to "the treatment of heart wounds should be support Billroth and his negative view of surgeons surgical." Borchardt (50) provided evidence that who would attempt to repair cardiac injuries. the classical syndrome of pericardial tamponade Riedinger (34) in 1882 dismissed anyone who was often absent from the clinical presentation of would attempt to suture heart. Paget (35) states in these injuries. his classical textbook, Surgery of the Chest: Other important contributions made to cardiac "Surgery of the heart has probably reached limits injury management were by Ballance (51) in 1920, set by nature to all surgery." Still others were not whom delivered the Bradshaw lecture on surgery deterred. Del Vecchio (36) followed the footsteps of the heart, which to this day remains one of the of Block (33) and created a canine model in which most comprehensive treatises in cardiac injury he sutured the heart. management. Smith (52) in 1923 developed a The first attempt at repairing a cardiac injury comprehensive plan for cardiac injury was by Cappelen (37) in 1896 in Christiania (the old management and for the first time pointed out the name for Oslo). He repaired a laceration of the left dangers of disrhythmias during cardiac ventricle and ligated the distal left anterior manipulation. He also described the use of an descending coronary artery. The patient Allis clamp near the apex to stabilize and hold the succumbed in the immediate postoperative heart while sutures were being placed. He was period. Also in 1896, Farina (38) of Rome first to tabulate and analyze the mortality of Volüm 9 Say› 1 PENETRATING CARDIAC INJURIES. COMPLEX INJURIES ... 3 cardiac injuries stratified to the chambers injured exceeds 40 to 50% of the intravascular blood (52). volume, resulting in cessation of cardiac function Beck (4) in 1926 described the physiology of and whether a pericardial tamponade is present or cardiac tamponade and reported the results of absent (62). animal studies. Similarly, Shoenfeld (53) in 1928, Beck’s Triad (4) represents the classical and Bigger (54) in 1939 reported their collective presentation of the patient arriving in the experiences in the management of cardiac emergency department with a full blown injuries. Elkin (55) in 1941 recommended the use pericardial tamponade. Kussmaul’s sign originally of fluoroscopy to assess cardiac motion and described as jugular venous distention upon alerted surgeons to the danger of ice pick injuries expiration is another classic sign attributed to while describing the advantages and pericardial tamponade.
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