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Blunt traumatic rupture of the heart
J THORAC CARDIOVASC SURG 81:574-576, 1981
Blunt traumatic rupture of the heart Successful repair of simultaneous rupture of the right atrium and left ventricle A case is reported of a 48-year-old man who sustained simultaneous rupture of the right atrium and left ventricle following blunt trauma in a motor vehicle accident. Rupture of one or more cardiac chambers in blunt cardiac trauma is not uncommon. However. survival to reach the hospital is rare. The clinical features of cardiac rupture are those of pericardial tamponade or hemorrhage. depending on whether or not the pericardium is intact. Successful management of cardiac rupture in the few reported survivors has depended on a high index of suspicion when signs of tamponade occur after blunt injury. Prompt exploration is essential. as few patients survive longer than 60 minutes after injury. Ready availability of cardiopulmonary bypass is emphasized. Atrial rupture can be managed without bypass, but left ventricular rupture. as in this case, would seem impossible to repair without it.
Paul Nicholas Hendel, M.B., B.S., F.R.A.C.S.,* and Alexander Falconer Grant, M.B.E., M.B., B.S., F.R.C.S., F.R.A.C.S.,** Sydney, Australia
Cardiac trauma is common in blunt injuries of the chest. In an autopsy series of 546 cases of blunt cardiac trauma, 64% were found to have rupture of one or more of the cardiac chambers.' Survival after cardiac rupture is not common, but a significant percentage of patients with atrial rupture will reach the hospital alive. Since the first report of successful repair of a ruptured right atrium by Desforges, Ridder, and Lenoci" in 1955, a small number of survivors of isolated rupture of either the right or left atrium and two survivors of right ventricular rupture have been reported. 3- 11 We have recently treated a patient who sustained simultaneous rupture of the right atrium and left ventricle. To our knowledge, this patient is doubly unique as the first survivor of a rupture of two chambers or of the left ventricle.
Case report A 48-year-old man was admitted from a peripheral hospital in Sydney, Australia, on May 11, 1979, about 10 hours after From Royal Prince AlfredHospital, Sydney, Australia. Received for publication Oct. 17, 1979. Accepted for publication Aug. 14, 1980. Address for reprints: Dr. N. Hendel, Senior Registrar, Wessex Cardiac and Thoracic Centre, Southampton Western Hospital, Oakley Road Southampton, S09 4WQ, United Kingdom. *SeniorRegistrar, Cardiothoracic Surgery Unit. **Headof Department of Cardiothoracic Surgery; Visiting Surgeon.
574
having been involved in a high-speed motor vehicle accident. He was the driver of a car which struck a telegraph pole, and he was not wearing a seat belt. The accident occurred about 60 miles from the city. He was initially admitted to a small local hospital, where rupture of the spleen was suspected, and he was transferred to another hospital in the city. On arrival there, a chest roentgenogram showed multiple bilateral rib fractures, a left hemopneumothorax, and a right pleural effusion. Bilateral chest tubes were inserted. The tube in the left side drained 300 rnl and the one in the right side drained 1,500 ml of blood, and both then stopped draining. The chest x-ray film also showed an elevated right hemidiaphragm, and this in combination with frank blood on abdominallavage suggested rupture of the liver. The man was transferred to the operating theater after being resuscitated. A laparotomy disclosed multiple lacerations of the liver, which were not actively bleeding. These were repaired, and he was transferred to the intensive care unit, intubated on a respirator. A postoperative chest x-ray film showed significant widening of the mediastinal shadow compared with the preoperative film. A ruptured aorta was suspected and the patient was transferred to this hospital for further management. On arrival he was hypotensive, with the systolic blood pressure being 60 mm Hg. The facial vessels were congested and the central venous pressure was 30 ern H20 . Heart sounds were faint. The clinical picture was one of cardiac tamponade. The chest tube in the right side had commenced draining blood again, and his condition was rapidly deteriorating. Although the possibility of an aortic rupture was considered, an aortogram was not performed for a number of reasons. The most important was the extremely rapid deterioration in the patient's condition. Brisk venous bleeding was
0022-5223/81/040574+03$00.30/0 © 1981 The C. V. Mosby Co.
Volume 81
Traumatic rupture of heart
Number 4
575
April. 1981
Fig. 1. Anterior view showing right atrial rupture.
Fig. 2. Posterior view showing left ventricular rupture.
occurring from the right side of the chest, but there was no drainage from the left and tamponade was rapidly worsening. It was felt that even with pericardiocentesis he would not survive the transfer to the x-ray department and the delay involved. Review of the chest films showed that there was little upper mediastinal widening. Previous experience with a patient with atrial rupture, as well as the signs of tamponade and venous blood from the right side of the chest, suggested atrial rupture. He was transferred to the operating theater immediately. The right femoral artery was cannulated as the man was being anesthetized. A median sternotomy was then performed. This incision was chosen despite the unresolved question of aortic rupture, because the most important consideration was rapid exposure of the right side of the heart. Furthermore, this incision could be extended with a left anterior thoracotomy if the need arose. When the chest was open, a vertical tear in the pericardium extending into the right pleural cavity was found and was extended to expose the heart. A large amount of clot was found around the right atrium. On removal of the clot, a 3 cm tear extending from the right atrial appendage into the free wall of the right atrium was disclosed (Fig. 1). This was occluded digitally while a partial occlusion clamp was applied. Simultaneously, the cardiotomy sucker was used to supply blood to the heart-lung machine for reinfusion through the femoral artery cannula. The right atrial tear was repaired with Teflon-buttressed Prolene sutures and the clamp was released. The patient's condition had improved rapidly following release of the tamponade. After repair of the atrium, bright red blood was noted coming from the left side of the pericardium. However, when
the heart was elevated to look for a source, hypotension ensued. A mass could be felt on the posterolateral wall of the left ventricle. Consequently, a cannula was placed into the right atrium and cardiopulmonary bypass was instituted. The left ventricle was vented through the apex and moderate hypothermia (30 C) was employed. The heart was again elevated and the left ventricle inspected. Another tear was found in the posterolateral wall of the left ventricle. This was 5 to 6 em long and extended perpendicular to the atrioventricular groove, beginning 2 em from the groove and lying between the obtuse marginal and posterolateral branches of the left circumflex artery (Fig. 2). This tear was plugged with a blood clot, which was removed. The ventricle was inspected through the tear for any fragments of clot. The tear was then repaired with Teflonbuttressed sutures in the same fashion as a ventricular aneurysm. Cardiopulmonary bypass then was discontinued with no difficulty and with excellent hemodynamic status. Routine chest closure was performed. In the recovery ward the patient initially progressed well. However, over the second and third postoperative days, ventilation became progressively more difficult to maintain with a pressure-cycled respirator. Fractional inspired oxygen (Flo,.) of 80% to 90% was needed to maintain an adequate Po 2 , and the chest x-ray film showed diffuse infiltrates. On the fourth day a tracheostomy was performed and ventilation commenced with a Bennett volume-cycled respirator. Initially, positive end-expiratory pressure of 10 cm H20 was used with an Flo.of 60%. However, this was reduced over the next few days and ventilation was discontinued after 9 days, at which time the tracheostomy tube was removed. The chest x-ray film cleared progressively. The laparot0
576 Hendel and Grant
omy, sternotomy, and groin incisions healed without problems, and he was discharged to a convalescent hospital on 1une 4, 1979. He spent a further 4 weeks there before returning home.
Discussion Survival for a sufficient length of time to reach the hospital after rupture of one of the cardiac chambers is uncommon. Bright and Beck" found that only 30 of 152 patients in their autopsy series survived for longer than I hour. Parmley, Manion, and Mattingly! similarly found that only 13 of 67 patients with atrial rupture survived longer than 30 minutes. Only one patient with ventricular rupture survived the initial injury, and this patient may have had delayed rupture of a myocardial contusion. Two patients surviving rupture of the right ventricle have been reported. 9. 11 Both of these presented in a similar fashion to patients with atrial rupture. All patients-"!' were in profound shock on arrival at the hospital where the cardiac operation was performed, and they were noted to have cyanosis and congestion of the vessels of the face, arms, and upper trunk. When the central venous pressure was measured, it was found to be markedly elevated, usually greater than 20 cm H 20 . The chest x-ray film was usually normal when the pericardium was intact, though some''- 5-7 showed rib fractures and/or widening of the mediastinum, as in our patient. When the pericardium was lacerated, the chest x-ray film showed hemothorax. Autopsy series!' !2have shown that the four cardiac chambers rupture with about equal frequency. However, in only 13 of 152 cases in one series" had two chambers ruptured, and none of these patients survived the initial injury. About 50% of patients 1 had severe associated injuries which could have resulted in death, but the remainder died solely of their cardiac trauma. The majority, 29 of 30 patients" died of cardiac tamponade; the other died of exsanguination. The extent of tamponade depends on whether or not the pericardium is intact. Tearing of the pericardium may allow partial release of tamponade while still controlling the rate of hemorrhage to some extent and thereby favors survival for a time.:" This mechanism appeared to have operated in our patient and allowed his survival through a laparotomy and two interhospital transfers. Also, the presence of a clot in the left ventricular rupture effectively prevented massive bleeding from this site. The successful management of these injuries has depended on early recognition through awareness of the
The Journal of Thoracic and Cardiovascular Surgery
problem. The presence of signs of cardiac tamponade or continued bleeding following closed chest trauma should indicate the need for early exploration. While atrial tears have been managed without cardiopulmonary bypass, the use of this technique makes the exploration much simpler from a number of points of view. First, massive, sudden bleeding may occur when the tamponade is released. As in our case, the presence of a femoral artery line enables the pump oxygenator set up for autotransfusion. Second, considerable manipulation may be required to expose and repair the injury. This can cause marked deterioration in the circulation. The ease with which bypass can be established when prior arterial cannulation has been performed makes control of hemorrhage from inaccessible sites much quicker and safer. The use of disposable oxygenators and no blood priming prevents any delay in operation while the circuit is being prepared. REFERENCES ParmleyLF, ManionWC, MattinglyTW: Nonpenetrating traumatic injury of the heart. Circulation 18:371, 1958 2 DesforgesG, RidderWP, Lenoci RJ: Successful suture of ruptured myocardium after nonpenetrating injury. N Engl 1 Med 252:567-569, 1955 3 Bogedain W, Carpathios 1, Van Suu D, Moots MF: Traumatic rupture of myocardium. lAMA 197:11021104, 1966 4 Miller GE, Rueb AE: Blunt thoracic trauma producing heart laceration. Ann Surg 166:852-853, 1967 5 Borja AR, LansingAM: Traumaticruptureofthe heart. A case successfully treated. Ann Surg 171:438-440, 1970 6 Siderys H, Strange PS: Rupture of the heart due to blunt trauma. 1 THORAC CARDIOVASC SURG 62:84-86, 1971 7 Noon GP, Boulafendis D, Beall AC lr: Rupture of the heart secondary to blunt trauma. 1 Trauma 11:122-128, 1971 8 O'Sullivan Ml, Spagna PM, Bellinger SB, Doohen OJ: Ruptureof the right atrium due to blunt trauma. 1 Trauma 12:208-214, 1972 9 TruebloodHW, Wuerflein RD, AngellWW: Blunttrauma rupture of the heart. Ann Surg 177:66-69, 1973 10 Smith 1M III, Grover FL, Marcos 11, Arom KV, Trinkle lK: Blunt traumatic rupture of the atria. 1 THORAC CARDIOVASC SURG 71:617-620, 1976 11 Rotman M, Peter RH, Sealy WC, Morris 11 Jr: Traumatic ventricular septal defect secondary to nonpenetrating chest trauma. Am 1 Med 48:127-131, 1970 12 BrightEF, Beck CS: Nonpenetrating woundsof the heart. A clinical and experimental study. Am Heart 1 10:293321, 1935 13 Liedtke Al, DeMuth WE Jr: Nonpenetrating cardiac injuries. A collectivereview. Am Heart186:687-697, 1973
Blunt traumatic rupture of the heart Successful repair of simultaneous rupture of the right atrium and left ventricle A case is reported of a 48-year-old man who sustained simultaneous rupture of the right atrium and left ventricle following blunt trauma in a motor vehicle accident. Rupture of one or more cardiac chambers in blunt cardiac trauma is not uncommon. However. survival to reach the hospital is rare. The clinical features of cardiac rupture are those of pericardial tamponade or hemorrhage. depending on whether or not the pericardium is intact. Successful management of cardiac rupture in the few reported survivors has depended on a high index of suspicion when signs of tamponade occur after blunt injury. Prompt exploration is essential. as few patients survive longer than 60 minutes after injury. Ready availability of cardiopulmonary bypass is emphasized. Atrial rupture can be managed without bypass, but left ventricular rupture. as in this case, would seem impossible to repair without it.
Paul Nicholas Hendel, M.B., B.S., F.R.A.C.S.,* and Alexander Falconer Grant, M.B.E., M.B., B.S., F.R.C.S., F.R.A.C.S.,** Sydney, Australia
Cardiac trauma is common in blunt injuries of the chest. In an autopsy series of 546 cases of blunt cardiac trauma, 64% were found to have rupture of one or more of the cardiac chambers.' Survival after cardiac rupture is not common, but a significant percentage of patients with atrial rupture will reach the hospital alive. Since the first report of successful repair of a ruptured right atrium by Desforges, Ridder, and Lenoci" in 1955, a small number of survivors of isolated rupture of either the right or left atrium and two survivors of right ventricular rupture have been reported. 3- 11 We have recently treated a patient who sustained simultaneous rupture of the right atrium and left ventricle. To our knowledge, this patient is doubly unique as the first survivor of a rupture of two chambers or of the left ventricle.
Case report A 48-year-old man was admitted from a peripheral hospital in Sydney, Australia, on May 11, 1979, about 10 hours after From Royal Prince AlfredHospital, Sydney, Australia. Received for publication Oct. 17, 1979. Accepted for publication Aug. 14, 1980. Address for reprints: Dr. N. Hendel, Senior Registrar, Wessex Cardiac and Thoracic Centre, Southampton Western Hospital, Oakley Road Southampton, S09 4WQ, United Kingdom. *SeniorRegistrar, Cardiothoracic Surgery Unit. **Headof Department of Cardiothoracic Surgery; Visiting Surgeon.
574
having been involved in a high-speed motor vehicle accident. He was the driver of a car which struck a telegraph pole, and he was not wearing a seat belt. The accident occurred about 60 miles from the city. He was initially admitted to a small local hospital, where rupture of the spleen was suspected, and he was transferred to another hospital in the city. On arrival there, a chest roentgenogram showed multiple bilateral rib fractures, a left hemopneumothorax, and a right pleural effusion. Bilateral chest tubes were inserted. The tube in the left side drained 300 rnl and the one in the right side drained 1,500 ml of blood, and both then stopped draining. The chest x-ray film also showed an elevated right hemidiaphragm, and this in combination with frank blood on abdominallavage suggested rupture of the liver. The man was transferred to the operating theater after being resuscitated. A laparotomy disclosed multiple lacerations of the liver, which were not actively bleeding. These were repaired, and he was transferred to the intensive care unit, intubated on a respirator. A postoperative chest x-ray film showed significant widening of the mediastinal shadow compared with the preoperative film. A ruptured aorta was suspected and the patient was transferred to this hospital for further management. On arrival he was hypotensive, with the systolic blood pressure being 60 mm Hg. The facial vessels were congested and the central venous pressure was 30 ern H20 . Heart sounds were faint. The clinical picture was one of cardiac tamponade. The chest tube in the right side had commenced draining blood again, and his condition was rapidly deteriorating. Although the possibility of an aortic rupture was considered, an aortogram was not performed for a number of reasons. The most important was the extremely rapid deterioration in the patient's condition. Brisk venous bleeding was
0022-5223/81/040574+03$00.30/0 © 1981 The C. V. Mosby Co.
Volume 81
Traumatic rupture of heart
Number 4
575
April. 1981
Fig. 1. Anterior view showing right atrial rupture.
Fig. 2. Posterior view showing left ventricular rupture.
occurring from the right side of the chest, but there was no drainage from the left and tamponade was rapidly worsening. It was felt that even with pericardiocentesis he would not survive the transfer to the x-ray department and the delay involved. Review of the chest films showed that there was little upper mediastinal widening. Previous experience with a patient with atrial rupture, as well as the signs of tamponade and venous blood from the right side of the chest, suggested atrial rupture. He was transferred to the operating theater immediately. The right femoral artery was cannulated as the man was being anesthetized. A median sternotomy was then performed. This incision was chosen despite the unresolved question of aortic rupture, because the most important consideration was rapid exposure of the right side of the heart. Furthermore, this incision could be extended with a left anterior thoracotomy if the need arose. When the chest was open, a vertical tear in the pericardium extending into the right pleural cavity was found and was extended to expose the heart. A large amount of clot was found around the right atrium. On removal of the clot, a 3 cm tear extending from the right atrial appendage into the free wall of the right atrium was disclosed (Fig. 1). This was occluded digitally while a partial occlusion clamp was applied. Simultaneously, the cardiotomy sucker was used to supply blood to the heart-lung machine for reinfusion through the femoral artery cannula. The right atrial tear was repaired with Teflon-buttressed Prolene sutures and the clamp was released. The patient's condition had improved rapidly following release of the tamponade. After repair of the atrium, bright red blood was noted coming from the left side of the pericardium. However, when
the heart was elevated to look for a source, hypotension ensued. A mass could be felt on the posterolateral wall of the left ventricle. Consequently, a cannula was placed into the right atrium and cardiopulmonary bypass was instituted. The left ventricle was vented through the apex and moderate hypothermia (30 C) was employed. The heart was again elevated and the left ventricle inspected. Another tear was found in the posterolateral wall of the left ventricle. This was 5 to 6 em long and extended perpendicular to the atrioventricular groove, beginning 2 em from the groove and lying between the obtuse marginal and posterolateral branches of the left circumflex artery (Fig. 2). This tear was plugged with a blood clot, which was removed. The ventricle was inspected through the tear for any fragments of clot. The tear was then repaired with Teflonbuttressed sutures in the same fashion as a ventricular aneurysm. Cardiopulmonary bypass then was discontinued with no difficulty and with excellent hemodynamic status. Routine chest closure was performed. In the recovery ward the patient initially progressed well. However, over the second and third postoperative days, ventilation became progressively more difficult to maintain with a pressure-cycled respirator. Fractional inspired oxygen (Flo,.) of 80% to 90% was needed to maintain an adequate Po 2 , and the chest x-ray film showed diffuse infiltrates. On the fourth day a tracheostomy was performed and ventilation commenced with a Bennett volume-cycled respirator. Initially, positive end-expiratory pressure of 10 cm H20 was used with an Flo.of 60%. However, this was reduced over the next few days and ventilation was discontinued after 9 days, at which time the tracheostomy tube was removed. The chest x-ray film cleared progressively. The laparot0
576 Hendel and Grant
omy, sternotomy, and groin incisions healed without problems, and he was discharged to a convalescent hospital on 1une 4, 1979. He spent a further 4 weeks there before returning home.
Discussion Survival for a sufficient length of time to reach the hospital after rupture of one of the cardiac chambers is uncommon. Bright and Beck" found that only 30 of 152 patients in their autopsy series survived for longer than I hour. Parmley, Manion, and Mattingly! similarly found that only 13 of 67 patients with atrial rupture survived longer than 30 minutes. Only one patient with ventricular rupture survived the initial injury, and this patient may have had delayed rupture of a myocardial contusion. Two patients surviving rupture of the right ventricle have been reported. 9. 11 Both of these presented in a similar fashion to patients with atrial rupture. All patients-"!' were in profound shock on arrival at the hospital where the cardiac operation was performed, and they were noted to have cyanosis and congestion of the vessels of the face, arms, and upper trunk. When the central venous pressure was measured, it was found to be markedly elevated, usually greater than 20 cm H 20 . The chest x-ray film was usually normal when the pericardium was intact, though some''- 5-7 showed rib fractures and/or widening of the mediastinum, as in our patient. When the pericardium was lacerated, the chest x-ray film showed hemothorax. Autopsy series!' !2have shown that the four cardiac chambers rupture with about equal frequency. However, in only 13 of 152 cases in one series" had two chambers ruptured, and none of these patients survived the initial injury. About 50% of patients 1 had severe associated injuries which could have resulted in death, but the remainder died solely of their cardiac trauma. The majority, 29 of 30 patients" died of cardiac tamponade; the other died of exsanguination. The extent of tamponade depends on whether or not the pericardium is intact. Tearing of the pericardium may allow partial release of tamponade while still controlling the rate of hemorrhage to some extent and thereby favors survival for a time.:" This mechanism appeared to have operated in our patient and allowed his survival through a laparotomy and two interhospital transfers. Also, the presence of a clot in the left ventricular rupture effectively prevented massive bleeding from this site. The successful management of these injuries has depended on early recognition through awareness of the
The Journal of Thoracic and Cardiovascular Surgery
problem. The presence of signs of cardiac tamponade or continued bleeding following closed chest trauma should indicate the need for early exploration. While atrial tears have been managed without cardiopulmonary bypass, the use of this technique makes the exploration much simpler from a number of points of view. First, massive, sudden bleeding may occur when the tamponade is released. As in our case, the presence of a femoral artery line enables the pump oxygenator set up for autotransfusion. Second, considerable manipulation may be required to expose and repair the injury. This can cause marked deterioration in the circulation. The ease with which bypass can be established when prior arterial cannulation has been performed makes control of hemorrhage from inaccessible sites much quicker and safer. The use of disposable oxygenators and no blood priming prevents any delay in operation while the circuit is being prepared. REFERENCES ParmleyLF, ManionWC, MattinglyTW: Nonpenetrating traumatic injury of the heart. Circulation 18:371, 1958 2 DesforgesG, RidderWP, Lenoci RJ: Successful suture of ruptured myocardium after nonpenetrating injury. N Engl 1 Med 252:567-569, 1955 3 Bogedain W, Carpathios 1, Van Suu D, Moots MF: Traumatic rupture of myocardium. lAMA 197:11021104, 1966 4 Miller GE, Rueb AE: Blunt thoracic trauma producing heart laceration. Ann Surg 166:852-853, 1967 5 Borja AR, LansingAM: Traumaticruptureofthe heart. A case successfully treated. Ann Surg 171:438-440, 1970 6 Siderys H, Strange PS: Rupture of the heart due to blunt trauma. 1 THORAC CARDIOVASC SURG 62:84-86, 1971 7 Noon GP, Boulafendis D, Beall AC lr: Rupture of the heart secondary to blunt trauma. 1 Trauma 11:122-128, 1971 8 O'Sullivan Ml, Spagna PM, Bellinger SB, Doohen OJ: Ruptureof the right atrium due to blunt trauma. 1 Trauma 12:208-214, 1972 9 TruebloodHW, Wuerflein RD, AngellWW: Blunttrauma rupture of the heart. Ann Surg 177:66-69, 1973 10 Smith 1M III, Grover FL, Marcos 11, Arom KV, Trinkle lK: Blunt traumatic rupture of the atria. 1 THORAC CARDIOVASC SURG 71:617-620, 1976 11 Rotman M, Peter RH, Sealy WC, Morris 11 Jr: Traumatic ventricular septal defect secondary to nonpenetrating chest trauma. Am 1 Med 48:127-131, 1970 12 BrightEF, Beck CS: Nonpenetrating woundsof the heart. A clinical and experimental study. Am Heart 1 10:293321, 1935 13 Liedtke Al, DeMuth WE Jr: Nonpenetrating cardiac injuries. A collectivereview. Am Heart186:687-697, 1973