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Late sequelae of penetrating cardiac wounds
Late sequelae of penetrating cardiac wounds Physiological and psychological parameters of 20 survivors of penetrating wounds of the heart were examined 7 to 52 months after recovery. All survivors had cardiac complaints. The psychological parameters for hypochondriasis, compulsiveness, and internalization were much greater in the patients than in control subjects but were similar to those in victims of violent major abdominal trauma. Physiological abnormalities were present in 19, although no particular pattern or abnormality could be related with certainty to the type of wound, operative procedure, or postoperative course. One recovered and re-employed victim required late surgical repair of a traumatic ventricular septal defect and ventricular diverticulum. Although functional work capacity measured by stress testing was normal in 90 percent, only eight survivors resumed employment. Complete rehabilitation was impaired by a residual traumatic neurosis. Management goals for patients with penetrating cardiac wounds should be broadened to include prevention of psychological disabilities.
Joseph A. Abbott, M.D., Martin Cousineau, B.S., Melvin Cheitlin, M.D., Arthur N. Thomas, M.D., and Robert C. Lim, Jr., M.D.,
San Francisco Calif.
Successful revival of a virtually dead victim of a gunshot or stab wound of the heart is a most gratifying experience. Initially, management of such trauma centers on the pathophysiological derangements that accompany such wounds, and therapy is well defined." However, a systematic analysis of the long-term physiological and psychological sequelae of penetrating cardiac injuries has not been reported. Many survivors of such injuries at San Francisco General Hospital Medical Center receive their total medical care at this large urban hospital. We have been impressed with the large number of postinjury complaints in these patients that seem to be out of proportion to the post-trauma physical abnormalities. Therefore, we systematically and objectively evaluated a large number of patients who had recovered from cardiac wounds to determine whether or not our subjective impressions were correct. The From the Medical and Surgical Services, San Francisco General Hospital Medical Center, and the Departments of Medicine and Surgery, the University of California, San Francisco, San Francisco, Calif. This work was performed while Mr. Cousineau was a summer student of the California Heart Association. Presented at the Third Annual Meeting of The Samson Surgical Society, Colorado Springs, Colorado, June 4-7, 1977. Address for reprints: Editorial Office, R410 I, 5H I San Francisco General Hospital Medical Center, 1001 Potrero Ave., San Francisco, Calif. 94110.
510
documented results of these evaluations have led us to broaden our treatment goals.
Patients and methods All patients admitted to the San Francisco General Hospital between January, 1972, and December, 1976, for penetrating wounds to the heart or great vessels were included in the study. The extent and location of the wound were determined in each patient by direct surgical inspection. Operative notes and problemoriented medical records gave detailed descriptions of the status of the victim on admission, the type of weapon used in the attack, the operative procedures performed, whether the patient died or survived, and the postoperative complications. Of the 60 patients admitted for such wounds, 32 died, 22 of whom were not successfully resuscitated or died within the first 48 hours, many from massive trauma related to gunshot wounds of the left side of the heart or coronary lacerations. The surgical mortality rate was high because it is our surgical policy.f as well as that of others.v 4 to attempt open chest cardiac resuscitative maneuvers on all moribund victims of penetrating chest wounds even though the victim may be clinically dead. Six of the remaining 10 patients who died between the second and seventh days of hospitalization died from noncardiac complications of associated injuries. Two resuscitated patients died from cerebral hypoxia, one patient died
0022-5223/78/0475-0510$00.90/0 © 1978 The C. V. Mosby Co.
Volume 75
Penetrating cardiac wounds
Number 4
5II
April,1978
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6 5 Patients 4
3
Fig. 1. Physiological effects of penetrating cardiac wounds in 20 survivors. The numbers in the columns indicate the number of patient s with the abnormality. There was no relationship of the type of wound to the abnormalities and many survivors had multiple abnormalities. V.S.D., Ventricular septal defect. R.A .D. , Right axis deviation .
from overwhelming systemic sepsis, and one patient died from a blunt cerebral injury 9 months after discharge. Twenty of the 28 victims who had recovered from their cardiac wounds and had been discharged from the hospital for at least 7 months consented to the testing procedures. Only historical data were available in five others who were contacted directly or through family members, and three could not be located. Twenty patients, ranging from 20 to 70 years of age (mean 35 years) , were evaluated extensively by historical interrogation and physical, physiological, and psychological testing . In obtaining the medical history, we emphasized the pretrauma work history and the presence of any pretrauma cardiovascular complaints or abnormal physical findings as well as postdischarge symptoms and re-employment information. A miniature Minnesota Multiphasic Personality Inventory (MMPI) modified by the University of California School of Public Health, Berkeley, California, was completed by each subject. In addition to a complete physical examination, a resting electrocardiogram, posteroanterior and left lateral roentgenograms, an echocardiogram, and treadmill stress test using the Bruce protocol were carried out. The technical details of these procedures, as used and interpreted in our laboratory, were reported previously. 5. 6 In patients with cardiomegaly, identified by roentgenography, heart wall motion and angiographic studies were performed with 99'fc-Iabeled albumin." If the exercise stress test produced pain and/or depression of the ST segment indicative of myocardial ischemia, myocardial heart scan with 20lTI was also performed." Nineteen em-
ployees (janitors) at San Francisco General Hospital Medical Center served as control subjects for the MMPI evaluation. All were approximately the same age as the patients, all were moderately active physicalIy, two were women, all were black, and all lived in the same postal zip code area as 15 of the patients. In addition, 17 other patients who had recovered from gunshot or stab wounds to the abdomen and had been discharged from the hospital at least 2 years were contacted and took the MMPI evaluation. All of these patients were of the same sex, race, and approximate age of the victims with cardiac wounds and had similar attack details .
Results The sex, race, preattack work history, attack details, clinical state, type of wound, and operative procedure performed on admission for all patients are summarized in Table I. No patient had preinjury cardiac complaints or abnormalities. Six survivors were considered clinically dead with no evidence of life on admission to the emergency room; all responded promptly to resuscitative measures, which required thoracotomy in all cases. Eighteen patients had clinically obvious pericardial tamponade that was documented by direct surgical inspection via a thoracotomy or laparotomy or both; all were promptly revived by pericardiotomy with relief of tamponade. All 20 survivors had postoperative evidence of pericarditis, manifested clinically by a pericardial friction rub, by classic serial electrocardiographic changes, or by both.
The Journal of
5 12 Abbott et al.
Thoracic and Cardiovascular Surgery
Table I. Background and clinical and laboratory findings in 20 survivors of penetrating cardiac wounds
Traumatic background
Date of injury
Type of injury and condition *
Type of surgery
42)W/M
Yes, (cook, alcoholic)
Argument (money)
Aug. 18, 1972
MSW, "died"
T
PT and LV
60
CP, Fat.
2
70/W/M
Robbery
L
PT
51
Fat.
28/B/M
SW, shock
T
PT and RV
45
CP
4
5I/B/M
Argument (drugs) Argument (lovers)
Nov. 21, 1972 Oct. 12, 1972 Dec. 5, 1972
MSW, shock
3
No (retired teacher) Yes (laborer, exfelon, exaddict) Yes (janitor)
5
45/B/M
Yes (laborer, alcoholic)
Argument (drinking)
6
22)C/M
Yes (clerk)
7
25/0/F
Yes (student)
8
Age (yr.)/ race/sex
Follow-up time (mo.)
Employed (job and social history)
Patient No.
35/0/M
Yes (waiter)
Oper. diag .
History
GSW, shock
TandL
PT
43
SOB, Fat.
Jan. 12, 1973
MSW, shock
TandL
PT
31
CP
Argument (racial) Attempted rape Argument (drugs)
Jan. 27, 1973 Mar. 28, 1973 Nov. 13, 1973
MSW, shock
L
PT
32
CP
MSW, shock
L
Apex
32
Fat.
SW, shock
T
PT and RA
32
SOB, Fat.
Argument
Dec. 25, 1973 Sept. 16, 1974 Oct. 5, 1974 July 10, 1975 Aug. 4, 1975 Sept. 9, 1975 Feb. 7, 1976 Feb. 22, 1976
MGSW
T
PT and RV
31
CP, SOB
SW, "died"
T
PT and RV
28
SW, "died"
TandL
PT and RV
20
CP, SOB, Fat, CP, SOB
9
22)B/M
10
22)B/M
II
30/B/M
12
26/0/F
Yes (truck driver, felon) Yes (cook, exaddict) Yes (laborer, exaddict, ex felon) Yes (clerk)
13
53/B/M
Yes (laborer)
14
56/B/M
Yes (laborer)
15
22)W/M
Yes (painter)
16
25/W/M
Yes (tradesman)
17
20/W/M
18
29/B/M
19
54/B/M
Yes (janitor, alcoholic) Yes (painter, exfelon, exaddict) No (prior GSW)
Argument (racial) Argument (drugs) Argument (family)
20
29/C/M
Yes (clerk)
Robbery
Argument Argument (drugs) Suicide (love) Argument (lovers) Argument (lovers) Argument (racial) Robbery
SW, shock
T
PA
12
SOB
SW, shock
T
PT and RV
11
SW, shock
T
15
CP, SOB, Fat. CP
10
SOB, Fat.
II
CP
SW, "died"
TandL
PT and IV septum PT and RV
SW, "died"
T
PT and RV
July 2, 1976 July 5, 1976 Oct. 22, 1976
SW
L
PT
8
Fat.
SW, "died"
T
PT and RA
8
CP
GSW, shock
T
PT and LV
7
CP, SOB, Fat.
Nov. 12, 1976
SW, shock
T
PT and RV
7
CP
Legend: Ab, Abnormal. AI, Aortic insufficiency. ASMI, Anteroseptal myocardial infarction. B, Black. C, Chicano. C-Meg., Cardiomegaly. CPo Chest pain.
CXR, Chest X-ray. DWC, Decreased work capacity. ECG, Electrocardiogram. Echo., Echocardiogram. F, Female. Fat., Fatigue. FM, "Functional" munnur. GSW, Gunshot wound. GXT, Graded exercise testing. IMI. Inferior myocardial infarction. IRBBB, Incomplete right bundle branch block. IV Septum, Intraventricular septum. L, Laparotomy. LASH, Left anterior superior hemiblock. L-R. Left-to-right. LV, Left ventricular laceration. M, Male. MGSW, Multiplegunshot wounds. MSW, Multiple stab wounds. N, Normal, 0, Oriental. Oper. diag., Operative diagnosis. PA, Pulmonary artery laceration. PT, Pericardia! tamponade. RA, Right atrial laceration. RAD, Right axis deviation. RV, Right ventricular laceration. RVE, Right ventricular enlargement. SOB, Shortness of breath. SW, Single stab wound. T, Thoracotomy. Tl, Tricuspid insufficiency. VD, Ventricular diverticulum. VF, Ventricular fibrillation. VSD, Ventricular septa! defect. VT, Ventricular tachycardia. W, White. ·Condition at injury revealed "nonnal" cardiovasculardynamics unless otherwise stated.
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Penetrating cardiac wounds
Number 4 April, 1978
5 I3
Data obtained at time of study Physical
Comments
N
ASMI
C-Meg. general
AI
ST-T
N
AI
Pain and Ischemia N
TI
RAO
N
N
N
Left CMeg.
IMI and ASMI
Left CMeg.
Paradox septum
RYE and paradox septum N
N
Ab
N
N
N
Ab
Yes
N Ab
No (retired) No (pain)
Ab
Yes
Ab
No (pain)
Ab
Yes
N
N
N
N
ST-T
N
N
Ischemia, Prewound N N
FM
N
N
N
N
N
Yes
RYE and paradox septum Paradox septum Paradox septum Septal hypokinesis N
N
Ab
No (frightened)
N
Ab
No (pain)
Ab
No
Ab
No (pain)
N
Yes
Ab
Ab
No (retired) No (retired) Yes
Ab
Yes
Ab
No (pain)
Ab
No (pain)
Ab
No (prior disability)
Right CMeg.
RAO, IRBBB
Right CMeg.
N
ST-T
N
N
N
N
ST-T
C-Meg. general N
Flail chest
Ischemia
TI
RAO, IRBBB N
N
ASMI
C-Meg. general N
TI
N
N
YSO
N
C-Meg. general
RYE
N
N
N
N
N
N
N
N
C-Meg. general
RYE
Pain and OWC Pain
N N
N
LASH, ST-T IRBBB
YT(off quinidine)
N
N
Paradox septum Paradox septum N
Paradox septum
N
N N
N N Pain and OWC N
N
The mean follow-up time for the group was 25 months, and the range was 7 to 60 months. All patients at the time of interview had one or more cardiac-like complaints. Physical examination and laboratory testing revealed residual abnormalities in all but one pa-
N N
Ab
YSO
N N
RY Enlarged
N
Yes
Postoperative coronary angio., circumflex disorder
Postoperative coma, I~ mo.
Psychotherapy
Catheterized twice; 2: I L-R shunt, YSO and YO
Postoperative YF
tient. The abnormalities were often multiple, but no abnormality correlated with the injury (Fig. I). Three patients (Nos. 3, 13, and 15) had an obvious murmur of triscupid insufficiency, one (No. 2) had aortic insufficiency, one (No. 16) had a ventricular septal de-
5I4
The Journal of Thoracic and Cardiovascular Surgery
Abbott et at.
Patients
rmal 90%
8
4
o
Work Capacity
Working
Cardiac Complaints
Fig. 2. Physiological work capacity, cardiac complaints, and post-trauma employment status in 20 survivors of penetrating cardiac wounds. The dotted line in the workingcolumn separates those who were unemployed before injury (two patients) from those who were employed (18 patients). feet, and one (No .7) had a functional basal murmur. Only seven patients had no electrocardiographic abnormalities. A healed myocardial infarction was obvious on the electrocardiograms of three patients (Nos. I, 4, and 14); in each, the electrocardiographic hallmarks were present on the immediate postoperative electrocardiograms, although this fact was not appreciated by the attending staff at that time because of the concomitant changes of acute pericarditis. An electrocardiogram obtained in one of these three patients (No. 14) during a routine health examination 2 months before the cardiac injury showed no evidence of infarction or other abnormalities. Five patients (Nos. 2, 6, 9, II, and 18) had nonspeci fie abnormalities of the ST-T wave on the resting electrocardiogram that were probably residual effects of the trauma-associated pericarditis. Five patients (Nos. 3, 8, 12, 18, and 19) had abnormal axis deviations or conduction defects or both. Another (No . 20) had asymptomatic bursts of ventricular tachycardia that were easily suppressible with quinidine . Seven patients (Nos . I, 4, 8, 10, 13, 16, and 19) had roentgenographic evidence of cardiomegaly: The right side of the heart was enlarged in one (No.8); the left side of the heart was enlarged in another (No.4); and the entire heart was enlarged in five. All of these
seven patients had abnormal radioisotopic angiograms or echocardiograms. However, over-all there was poor correlation of chamber abnormality among roentgenogram, radioisotope angiogram, and echocardiogram. The acquired ventricular septal defect noted during the physical examination of Patient 16 was apparent on a radioisotope angiogram. The location and magnitude of the defect were determined during two post-traumatic catheterizations of the heart performed 9 months apart, the last one conducted I year after the injury. Both of these studies documented a ventricular septal defect high in the septum, the presence of a left-to-right shunt with the pulmonary blood flow twice that of systemic blood flow, and a small diverticulm of the left ventricular wall in the area immediately opposite the traumatically produced ventricular septal defect. There was no change in the magnitude of the shunt or enlargement of the diverticulum between the studies. The patient was asymptomatic, re-employed, and had a normal electrocardiogram and normal ventricular wall motion. The most common echocardiographic abnormality was paradoxic motion of the interventricular septum, which was present in eight patients (Nos. 1,4,8,9, 10, 13, 14, and 20). This was associated with right ventricular enlargement in two (Nos . 4 and 8) and was associated with electrocardiographic evidence of a remote anteroseptal myocardial infarction in three (Nos. I, 4, and 14). One patient (No . 20) had bouts of ventricular tachycardia but never during the echocardiography . Interventricular septal hypokinesis was present on the echocardiogram in Patient I I. Results of graded treadmill stress testing were within normal limits in 14 patients and abnormal in six. In three patients (Nos. 14, 18, and 19) stress-induced chest pain developed that was atypical of angina and was not accompanied by ischemic electrocardiographic changes. All three had normal myocardial radioisotope scans during exercise, and their symptoms were considered nonischemic in origin. Two of these three (Nos . 14 and 18) had a decreased age-predicted peak functional capacity, but the exercise levels they achieved were in excess of their pretrauma work requirements; Patient 19 was unemployed prior to his injury. Two other patients (Nos. 5 and II) had no cardiac symptoms during exercise and reached target heart rates, but stress-induced electrocardiographic changes occurred . Patient II had a normal myocardial scan, and Patient 5 had no abnormalities during a preinjury stress test given as part of a routine physical examination. This patient's postinjury myocardial scan was also normal, but a subsequent coronary angiogram revealed a significant lone
Volume 75
Penetrating cardiac wounds
Number 4 April,1978
5 15
100
80 w
ell:
o U
V>
~
tJJ
40
I-I" I -
I.R.l07
Q--1[---Q--~I--~~-Q ']:.. .
~-1
I.R.90
20 OL..-----:-'-------'----'-------'---...L.------l._--'----_L..-----'--_...L.------l._ _
Fig. 3. The Minnesota Multiphasic Personality Inventory T scales reveal significant differences and trends between the 20 recovered cardiac victims (solid line) and 19 control subjects (dotted line). The internalization ratio (I.R.) is indicated on the right and is significantly higher in the victims (107) than in the control subjects (90). lesion in the cirumflex coronary artery. The exerciseinduced electrocardiographic abnormalities in both of these patients could have been residual effects of the post-traumatic pericarditis. In one patient (No. I) atypical angina-like pain developed and ischemia was apparent during a myocardial radioisotope scan at work levels greater than those required by his job; this patient also had a healed anteroseptal myocardial infarction. He probably has coronary disease, although he related the onset of his symptoms to the traumatic injury. Twelve patients were unemployed after their injury (Fig. 2). Neither of the two victims (Nos. 2 and 19) who did not work prior to injury worked after the injury. Six patients (Nos. 3, 5, 9, II, 17, and 18) had excessive chest pain when they returned to their previous employment duties and therefore were unable to resume employment. Two patients (Nos. 13 and 14) noted excessive fatigue when they attempted to return to their jobs and therefore retired prematurely. One patient (No. 10) had mild permanent neurologic damage as a result of his wounds and could not perform his prior duties as a cook. Patient 8 was excessively anxious and reported that his heart could not withstand the stresses of his previous employment and therefore remained unemployed. All 10 of these patients who did not resume their jobs after injury had exercise stress tests that documented physiological ability to perform
work levels at or in excess of their preinjury work levels without untoward cardiac abnormalities. Only two of the five patients who refused testing but whom we contacted via telephone or friends had returned to work. The other three who had previously been employed expressed continued anxiety about their cardiac wounds and related their failure to return to gainful employment to their injury. Nineteen of the patients received no psychological evaluation or therapy during or after hospitalization. One patient (No. 12), whose wound was sustained in an attempted suicide, underwent I year of posthospitalization psychotherapy. Our psychologic testing revealed that four patients, including Patient 12, had normal results, but 16 patients had abnormal psychological indexes. The results of the psychological tests of the recovered victims of cardiac wounds are compared with those of the 19 control subjects (hospital employees) in Fig. 3. Hypocondriasis, compulsiveness, and internalization were significantly greater (p < 0.05) in the recovered victims. These symptoms are commonly associated with a neurotic state. The tests for the cardiac patients also demonstrated depression, hysteria, psycopathic deviation, and schizophrenic behavior more frequently than those for the control subjects, but the difference was not statistically significant. Two of the cardiac patients had abnormally
The Journal of
5 I 6 Abbott et al.
high lying or cheating scores; thus their psychological data were excluded from analysis. Comparison of the psychological tests of our patients with the 17 patients who had recovered from major traumatic gunshot or stab wounds of the abdomen revealed similar results in every detail with no significant differences. We therefore attributed the abnormal psychological results to the traumatic experience and not specifically to cardiac trauma.
Discussion Previous reports of victims survivmg penetrating cardiac wounds emphasized the high incidence of chronic psychological disability in such patients. Steffens" in 1936 reported a two-decade follow-up of 109 veterans of World War I with healed bullet wounds of the heart. Only 13 percent of the veterans were free of symptoms; the remainder had complaints that were considered by Steffens to be psychogenic rather than physicogenic. Bland and Beebe!" reported a 20 year follow-up of 40 World War II veterans with retained missiles in the heart. They emphasized the low frequency of physiological disability. Indeed, only two of the patients had severe valvular insufficiency. However, 17 patients had cardiac-like symptoms and frank anxiety was identified in seven. Five of these seven were unable to work. Noth!' reported cardiac symptoms in all 14 survivors of penetrating cardiac wounds treated at a civilian hospital. He attributed the symptoms to neurosis in each case. These three reports implied that the psychological neurosis of the patients was attributable to the fact that the heart was the organ affected. None of the studies contained detailed psychological information nor was objective psychological testing performed. Our study is unique in that we performed both objective psychological and physiological tests and compared our survivors with survivors of major life-threatening traumatic wounds of other organs and with control subjects with socieconomic backgrounds similar to those of our patients. These comparisons revealed that the psychological abnormalities in our patients were secondary to the traumatic episode and were not unique to those suffering cardiac trauma. Thus if neurosis develops after a penetrating cardiac wound, it probably is strictly a traumatic neurosis, the dynamics of which are well known. 12 The syndrome results from any injury causing great fright. The fright may result in long-lasting, if not permanent, anxiety and dependence that are often associated with a multitude of somatic complaints without identifiable organic cause. Patients with traumatic neurosis frequently do not function normally socially and the per-
Thoracic and Cardiovascular Surgery
manent unemployment rate is high. The chronicity of the syndrome is directly related to the lack of prompt postinjury psychological therapy;" Symbas and associates'" reported 16 cases of delayed cardiac sequelae in 56 patients followed for 6 to 19 months after sustaining a penetrating cardiac wound. There was a high frequency of shunts between cardiac chambers of great vessels, valve lesions, and traumatic ventricular aneurysms. However, he did not detail the functional impairment of the 16 patients. Syrnbas" emphasized the need for follow-up surgical repair if such lesions were of frank hemodynamic significance or if a traumatic ventricular aneurysm were discovered. Only one (No. 16) of our survivors has required subsequent surgical repair; he had a hemodynamically significant ventricular septal defect that did not close and a traumatic diverticulum of the left ventricle. Other investigators also emphasized the need for definitive surgical correction in some patients with traumatic cardiac lesions.l'"?" Heller and co-workers" reported on 27 patients from an urban general hospital who suffered traumatic cardiac wounds. They emphasized early cardiac sequelae with these injuries. They specifically identified the early postoperative electrocardiographic abnormalities and documented the presence of acute pericarditis in all victims. In addition, they noted a high frequency of pericardial tamponade, conduction defects including complete heart block, and electrocardiographic evidence of myocardial infarction. Cardiac murmurs from either ventricular septal defects or presumed tricuspid or aortic insufficiency developed in six of their patients. However, the follow-up time was short because many of the patients were lost to follow-up, and thus only fragmentary and anecdotal information was available regarding the functional capacities of the patients. Other investigators also reported the high frequency of electrocardiographic abnormalities, namely pericarditis, conduction defects, and myocardial infarction, in survivors of cardiac trauma. II, 20 However, the results of the extensive physiological tests in our patients provide greater information about the extent of physiological recovery from traumatic cardiac wounds. Only one of our patients (No. 17) had completely normal physiologic test results. Most survivors had readily identifiable physiological deficits. Eight patients had frank valvular leaks, a hemodynamically significant ventricular septal defect, or myocardial infarction. Six had paradoxic or abnormal motion of the interventricular septum, which has not been described heretofore. We are uncertain of the cause of this disorder, but a similar phenomenon was observed in patients after cardiac bypass and was
Volume 75
Penetrating cardiac wounds
Number 4 April,1978
attributed to pericardiotomy. 21 Pericardiotomy was performed in all six of these patients, and this, rather than a conduction defect or myocardial depression, could be the cause of the abnormal motion. Persistent ventricular ectopia that required months of treatment with an antiarrhythmic agent was present in one (No. 20) of our patients. This phenomenon has not been reported previously in patients with cardiac wounds; its origin is unclear. Some of the abnormalities that we identified were probably present at the time of or immediately after the initial injury. For example, in three of our patients the diagnosis of myocardial infarction was not made at the time of surgical recovery, although review of the postoperative electrocardiograms revealed its presence in each patient. The electrocardiographic abnormalities probably were falsely attributed to coexistent changes of acute post-traumatic pericarditis. However, the only murmur immediately obvious at the time of injury was in the victim with the ventricular septal defect. Ten of our patients who previously had been productive members of society tried to resume employment unsuccessfully. Graded exercise testing proved that only two (Nos. 12 and 14) of the ten had decreased physiological functional capacity that clearly required them to alter their postinjury stress but not their work activities. In the remaining eight, exercise capacity was not abnormal and unemployment was related to psychological abnormalities. An undiagnosed and untreated traumatic neurosis proved to be the major impediment to re-employment. This suggests that a more vigorous emphasis should be placed on the psychological rehabilitation of the survivors of a penetrating cardiac wound, which should probably begin during hospitalization. This is perhaps corroborated by the case (Patient 12) in which psychotherapy was initiated immediately because the wound was sustained in a suicide attempt. The patient had a normal psychological profile at the time of testing and was re-employed. We recommend that changes in the management of patients recovering from penetrating cardiac wounds be implemented. Specifically, victims of such wounds should be followed systematically by both the surgeon and intemist to ensure that victims with myocardial infarctions or serious ventricular arrhythmias receive appropriate treatment. We also recommend that early psychological rehabilitation be carried out to prevent the psychological disabilities identified in our study. Furthermore, victims of a cardiac wound should be assessed for their physiological recuperative potential and then be subjected to a graded stress test after recovery, if only for reassurance. Both physiological and
5 I7
psychological testing allow the surgeon and the internist to define the mechanism of each individual victim's problems and permit a rational approach to long-term management. We thank E. B. Raftery, M.D., of London, England, for performing the physiological testing for Patient 7. Patient 16 is a patient of Donald McDonald, M.D., of Vallejo, California; corrective surgery was performed by Norman Shumway, M.D., of Stanford University Medical Center, Palo Alto, California. REFERENCES
2 3 4
5
6
7
8
9 10
II 12 13 14
15 16
Parmley LF, Mattingly TW, Manion WC: Penetrating wounds of the heart and aorta. Circulation 17:953, 1958 Lim RC Jr: Evaluation and immediate management of open chest wounds. Hosp Med 11:8, 1975 Ebert P: Cardiac injuries (trauma rounds). West J Med 125:85, 1976 Beach PM Jr, Bognolo D, Hutchinson JE: Penetrating cardiac trauma. Experience with thirty-four patients in a hospital without cardiopulmonary bypass capability. Am J Surg 131:411, 1976 Abbott JA, Tedeschi MA, Cheitlin MD: Graded treadmill stress testing. Patterns of physician use and abuse. West J Med 126:173, 1977 Rolston WA, Hirschfeld DS, Emilson BB, Cheitlin MD: Echocardiographic appearance of ruptured aortic cusp. Am J Med 62:133, 1977 Zaret BL, Strauss HW, Hurley PJ, Natarajan TK, Pitt B: A noninvasive scintiphotographic method for detecting regional ventricular dysfunction in man. N Engl J Med 284: 1165, 1971 Strauss HW, Harrison K, Langan JK, Lebowitz E, Pitt B: Thallium-20J for myocardial imaging. Relation of thallium-201 to regional myocardial perfusion. Circulation 51:641,1975 Steffens W: Arbeit und Gesundheit Heft 27. Herzsteckschusse , Leipzig, 1936, Georg Thieme Bland EF, Beebe GW: Missiles in the heart. A twentyyear follow-up report of World War II cases. N Engl J Med 274:1039, 1966 Noth PH: Electrocardiographic patterns in penetrating wounds of the heart. Am Heart J 32:713, 1946 Keiser L: The Traumatic Neurosis. Philadelphia, 1968, J. B. Lippincott Co., p. 35 Rape Victimization Study, Queens Bench Foundation, San Francisco, 1975, p. 79 Symbas PN, DiOrio DA, Tyras DH, Ware RE, Hatcher CR: Penetrating cardiac wounds. Significant residual and delayed sequelae. J THORAC CARDIOVASC SURG 66:526, 1973 Symbas PN: Residual or delayed lesions from penetrating cardiac wounds. Chest 66:408, 1974 Singh R, Nolan SP, Schrank JP: Traumatic left ventricular aneurysm. Two cases with normal coronary angiograms. JAMA 234:412, 1975
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17 Pirzada FA, McDowell JW, Cohen EM, Saini VK, Berger RL: Traumatic ventricular septal defect. Sequential hemodynamic observations. N Engl J Med 291:892, 1974 18 Rayner A VS, Fulton RL, Hess PJ, Daicoff GR: Posttraumatic intracardiac shunts. Report of two cases and review of the literature. J THoRAc CARDIOVASC SURG 73:728, 1977 19 Heller RF, Rahimtoola SH, Ehsani A, Johnson S, Boyd DR, Tatooles CJ, Loeb HS, Rosen KR: Cardiac complications. Results of penetrating chest wounds involving the heart. Arch Intern Med 134:491, 1974 20 Gelfand ML, Maynard AD, Cord ice JWV, Nacheria EA: Follow-up electrocardiographic changes in penetrating wounds of the heart treated surgically. Angiology 8:272, 1957 21 Righetti A, Crawford MH, O'Rourke RA, Schelbert H, Daily PO, Ross J Jr: Interventricular septal motion and left ventricular function after coronary bypass surgery. Evaluation with echocardiography and radionuclide angiography. Am J Cardiol 39:372, 1977
Discussion DR. ROGER R. ECKER Oakland, Calif.
I would like to compliment Dr. Abbott and his co-workers on this very thoroughgoing and careful follow-up of the type of patient that we all see frequently. They are quite correct in saying that most of the physiological abnormalities which they documented were unsuspected. Many of us have seen these patients and, except for an isolated case of valve injury or ventricular septal defect, we seldom recognize any abnormality. Yet, there is a disastrous effect on the social adjustment of the patient, for he is not returning to work and has many fears and depressions. Ever since Ludwig Rehn performed the first successful suture of a cardiac wound in 1897, most surgeons have approached this operation in a similar manner. We are most interested in where the wound is, and the outcome is measured in terms of the surgical mortality rate. We were able to report some years ago from Parkland Hospital on 86 patients who arrived in the hospital with stab and gunshot wounds of the heart. However, it is important to remember that, in the same time period, four times as many patients, 373, also arrived by the back door. In other words, the problem does not begin in the emergency room. It begins at the site of injury, and I think that we may find that something can be done at the scene or quite early, as is done for heart attack victims. The treatment for gunshot and stab wounds of the heart has changed over the years, waxed and waned in favor of pericardiocentesis or surgery. We certainly favor surgery, and
Thoracic and Cardiovascular Surgery
we were able to reduce the mortality rate by an emphasis on prompt surgery. We have dispensed with treatment by pericardiocentesis except as a temporizing procedure. The mortality declined to as low as 5 percent for stab wounds and 24 percent for gunshot wounds or an over-all mortality of 15 percent for patients who arrived in the emergency room alive. We also studied a series of patients who had coronary artery wounds. In the earlier series of stab and gunshot wounds, some patients had coronary artery lacerations. In looking over our data, I found that we made no statement whatsoever about how many patients returned to work. In other words we ignored that aspect altogether. There were 22 patients with coronary artery lacerations, and a good number of them were dead on arrival. Fifteen were alive on arrival, and of the 15, 10 survivors left the hospital. We did follow up the 10 patients with coronary artery lacerations. One of them had a ventricular septal defect which had to be closed, and he went back to running track at his high school. I am sure we did not document the follow-up of the other 9 as carefully as Dr. Abbott, Dr. Thomas, and their colleagues have, but we stated that all returned to their former activities. That may mean fighting in bars, but they were able to return to what they did before. [Slide] This slide indicates the mortality rate from trauma in the United States for 1970. I am sure that the current figure is probably larger. In simply cataloging operative mortality rates from gunshot and stab wounds of the heart and from other trauma, we as thoracic surgeons perhaps are ignoring the larger picture. This study by Dr. Abbott and his colleagues points up another and a very important aspect. There are several other aspects which need to be addressed, such as the out-of-hospital mortality rate. Perhaps we should go on from there to the preventive aspects, to how we can reduce the number of people who are stabbed and shot. That may seem out of the question, but perhaps we can have some impact on it. I would not want to suggest gun control legislation, because that would be very unpopular. However, there may be things we can do in the preventive field. As thoracic surgeons, we should definitely be involved not only in the treatment of these patients to keep them alive, but in their rehabilitation as well. DR. A B BO TT (Closing) I would point out for those interested in the over-all social aspects of violent crimes that there was a Presidential Commission which extensively explored the root causes of violence in our society and which made very pertinent recommendations for prevention ("To Establish Justice, to Insure Domestic Tranquility. The Final Report of the National Commission on the Causes and Prevention of Violence." New York, 1970, Praeger Publishers, Inc.). Unfortunately, most of these recommendations have not been implemented.
Joseph A. Abbott, M.D., Martin Cousineau, B.S., Melvin Cheitlin, M.D., Arthur N. Thomas, M.D., and Robert C. Lim, Jr., M.D.,
San Francisco Calif.
Successful revival of a virtually dead victim of a gunshot or stab wound of the heart is a most gratifying experience. Initially, management of such trauma centers on the pathophysiological derangements that accompany such wounds, and therapy is well defined." However, a systematic analysis of the long-term physiological and psychological sequelae of penetrating cardiac injuries has not been reported. Many survivors of such injuries at San Francisco General Hospital Medical Center receive their total medical care at this large urban hospital. We have been impressed with the large number of postinjury complaints in these patients that seem to be out of proportion to the post-trauma physical abnormalities. Therefore, we systematically and objectively evaluated a large number of patients who had recovered from cardiac wounds to determine whether or not our subjective impressions were correct. The From the Medical and Surgical Services, San Francisco General Hospital Medical Center, and the Departments of Medicine and Surgery, the University of California, San Francisco, San Francisco, Calif. This work was performed while Mr. Cousineau was a summer student of the California Heart Association. Presented at the Third Annual Meeting of The Samson Surgical Society, Colorado Springs, Colorado, June 4-7, 1977. Address for reprints: Editorial Office, R410 I, 5H I San Francisco General Hospital Medical Center, 1001 Potrero Ave., San Francisco, Calif. 94110.
510
documented results of these evaluations have led us to broaden our treatment goals.
Patients and methods All patients admitted to the San Francisco General Hospital between January, 1972, and December, 1976, for penetrating wounds to the heart or great vessels were included in the study. The extent and location of the wound were determined in each patient by direct surgical inspection. Operative notes and problemoriented medical records gave detailed descriptions of the status of the victim on admission, the type of weapon used in the attack, the operative procedures performed, whether the patient died or survived, and the postoperative complications. Of the 60 patients admitted for such wounds, 32 died, 22 of whom were not successfully resuscitated or died within the first 48 hours, many from massive trauma related to gunshot wounds of the left side of the heart or coronary lacerations. The surgical mortality rate was high because it is our surgical policy.f as well as that of others.v 4 to attempt open chest cardiac resuscitative maneuvers on all moribund victims of penetrating chest wounds even though the victim may be clinically dead. Six of the remaining 10 patients who died between the second and seventh days of hospitalization died from noncardiac complications of associated injuries. Two resuscitated patients died from cerebral hypoxia, one patient died
0022-5223/78/0475-0510$00.90/0 © 1978 The C. V. Mosby Co.
Volume 75
Penetrating cardiac wounds
Number 4
5II
April,1978
7
6 5 Patients 4
3
Fig. 1. Physiological effects of penetrating cardiac wounds in 20 survivors. The numbers in the columns indicate the number of patient s with the abnormality. There was no relationship of the type of wound to the abnormalities and many survivors had multiple abnormalities. V.S.D., Ventricular septal defect. R.A .D. , Right axis deviation .
from overwhelming systemic sepsis, and one patient died from a blunt cerebral injury 9 months after discharge. Twenty of the 28 victims who had recovered from their cardiac wounds and had been discharged from the hospital for at least 7 months consented to the testing procedures. Only historical data were available in five others who were contacted directly or through family members, and three could not be located. Twenty patients, ranging from 20 to 70 years of age (mean 35 years) , were evaluated extensively by historical interrogation and physical, physiological, and psychological testing . In obtaining the medical history, we emphasized the pretrauma work history and the presence of any pretrauma cardiovascular complaints or abnormal physical findings as well as postdischarge symptoms and re-employment information. A miniature Minnesota Multiphasic Personality Inventory (MMPI) modified by the University of California School of Public Health, Berkeley, California, was completed by each subject. In addition to a complete physical examination, a resting electrocardiogram, posteroanterior and left lateral roentgenograms, an echocardiogram, and treadmill stress test using the Bruce protocol were carried out. The technical details of these procedures, as used and interpreted in our laboratory, were reported previously. 5. 6 In patients with cardiomegaly, identified by roentgenography, heart wall motion and angiographic studies were performed with 99'fc-Iabeled albumin." If the exercise stress test produced pain and/or depression of the ST segment indicative of myocardial ischemia, myocardial heart scan with 20lTI was also performed." Nineteen em-
ployees (janitors) at San Francisco General Hospital Medical Center served as control subjects for the MMPI evaluation. All were approximately the same age as the patients, all were moderately active physicalIy, two were women, all were black, and all lived in the same postal zip code area as 15 of the patients. In addition, 17 other patients who had recovered from gunshot or stab wounds to the abdomen and had been discharged from the hospital at least 2 years were contacted and took the MMPI evaluation. All of these patients were of the same sex, race, and approximate age of the victims with cardiac wounds and had similar attack details .
Results The sex, race, preattack work history, attack details, clinical state, type of wound, and operative procedure performed on admission for all patients are summarized in Table I. No patient had preinjury cardiac complaints or abnormalities. Six survivors were considered clinically dead with no evidence of life on admission to the emergency room; all responded promptly to resuscitative measures, which required thoracotomy in all cases. Eighteen patients had clinically obvious pericardial tamponade that was documented by direct surgical inspection via a thoracotomy or laparotomy or both; all were promptly revived by pericardiotomy with relief of tamponade. All 20 survivors had postoperative evidence of pericarditis, manifested clinically by a pericardial friction rub, by classic serial electrocardiographic changes, or by both.
The Journal of
5 12 Abbott et al.
Thoracic and Cardiovascular Surgery
Table I. Background and clinical and laboratory findings in 20 survivors of penetrating cardiac wounds
Traumatic background
Date of injury
Type of injury and condition *
Type of surgery
42)W/M
Yes, (cook, alcoholic)
Argument (money)
Aug. 18, 1972
MSW, "died"
T
PT and LV
60
CP, Fat.
2
70/W/M
Robbery
L
PT
51
Fat.
28/B/M
SW, shock
T
PT and RV
45
CP
4
5I/B/M
Argument (drugs) Argument (lovers)
Nov. 21, 1972 Oct. 12, 1972 Dec. 5, 1972
MSW, shock
3
No (retired teacher) Yes (laborer, exfelon, exaddict) Yes (janitor)
5
45/B/M
Yes (laborer, alcoholic)
Argument (drinking)
6
22)C/M
Yes (clerk)
7
25/0/F
Yes (student)
8
Age (yr.)/ race/sex
Follow-up time (mo.)
Employed (job and social history)
Patient No.
35/0/M
Yes (waiter)
Oper. diag .
History
GSW, shock
TandL
PT
43
SOB, Fat.
Jan. 12, 1973
MSW, shock
TandL
PT
31
CP
Argument (racial) Attempted rape Argument (drugs)
Jan. 27, 1973 Mar. 28, 1973 Nov. 13, 1973
MSW, shock
L
PT
32
CP
MSW, shock
L
Apex
32
Fat.
SW, shock
T
PT and RA
32
SOB, Fat.
Argument
Dec. 25, 1973 Sept. 16, 1974 Oct. 5, 1974 July 10, 1975 Aug. 4, 1975 Sept. 9, 1975 Feb. 7, 1976 Feb. 22, 1976
MGSW
T
PT and RV
31
CP, SOB
SW, "died"
T
PT and RV
28
SW, "died"
TandL
PT and RV
20
CP, SOB, Fat, CP, SOB
9
22)B/M
10
22)B/M
II
30/B/M
12
26/0/F
Yes (truck driver, felon) Yes (cook, exaddict) Yes (laborer, exaddict, ex felon) Yes (clerk)
13
53/B/M
Yes (laborer)
14
56/B/M
Yes (laborer)
15
22)W/M
Yes (painter)
16
25/W/M
Yes (tradesman)
17
20/W/M
18
29/B/M
19
54/B/M
Yes (janitor, alcoholic) Yes (painter, exfelon, exaddict) No (prior GSW)
Argument (racial) Argument (drugs) Argument (family)
20
29/C/M
Yes (clerk)
Robbery
Argument Argument (drugs) Suicide (love) Argument (lovers) Argument (lovers) Argument (racial) Robbery
SW, shock
T
PA
12
SOB
SW, shock
T
PT and RV
11
SW, shock
T
15
CP, SOB, Fat. CP
10
SOB, Fat.
II
CP
SW, "died"
TandL
PT and IV septum PT and RV
SW, "died"
T
PT and RV
July 2, 1976 July 5, 1976 Oct. 22, 1976
SW
L
PT
8
Fat.
SW, "died"
T
PT and RA
8
CP
GSW, shock
T
PT and LV
7
CP, SOB, Fat.
Nov. 12, 1976
SW, shock
T
PT and RV
7
CP
Legend: Ab, Abnormal. AI, Aortic insufficiency. ASMI, Anteroseptal myocardial infarction. B, Black. C, Chicano. C-Meg., Cardiomegaly. CPo Chest pain.
CXR, Chest X-ray. DWC, Decreased work capacity. ECG, Electrocardiogram. Echo., Echocardiogram. F, Female. Fat., Fatigue. FM, "Functional" munnur. GSW, Gunshot wound. GXT, Graded exercise testing. IMI. Inferior myocardial infarction. IRBBB, Incomplete right bundle branch block. IV Septum, Intraventricular septum. L, Laparotomy. LASH, Left anterior superior hemiblock. L-R. Left-to-right. LV, Left ventricular laceration. M, Male. MGSW, Multiplegunshot wounds. MSW, Multiple stab wounds. N, Normal, 0, Oriental. Oper. diag., Operative diagnosis. PA, Pulmonary artery laceration. PT, Pericardia! tamponade. RA, Right atrial laceration. RAD, Right axis deviation. RV, Right ventricular laceration. RVE, Right ventricular enlargement. SOB, Shortness of breath. SW, Single stab wound. T, Thoracotomy. Tl, Tricuspid insufficiency. VD, Ventricular diverticulum. VF, Ventricular fibrillation. VSD, Ventricular septa! defect. VT, Ventricular tachycardia. W, White. ·Condition at injury revealed "nonnal" cardiovasculardynamics unless otherwise stated.
Volume 75
Penetrating cardiac wounds
Number 4 April, 1978
5 I3
Data obtained at time of study Physical
Comments
N
ASMI
C-Meg. general
AI
ST-T
N
AI
Pain and Ischemia N
TI
RAO
N
N
N
Left CMeg.
IMI and ASMI
Left CMeg.
Paradox septum
RYE and paradox septum N
N
Ab
N
N
N
Ab
Yes
N Ab
No (retired) No (pain)
Ab
Yes
Ab
No (pain)
Ab
Yes
N
N
N
N
ST-T
N
N
Ischemia, Prewound N N
FM
N
N
N
N
N
Yes
RYE and paradox septum Paradox septum Paradox septum Septal hypokinesis N
N
Ab
No (frightened)
N
Ab
No (pain)
Ab
No
Ab
No (pain)
N
Yes
Ab
Ab
No (retired) No (retired) Yes
Ab
Yes
Ab
No (pain)
Ab
No (pain)
Ab
No (prior disability)
Right CMeg.
RAO, IRBBB
Right CMeg.
N
ST-T
N
N
N
N
ST-T
C-Meg. general N
Flail chest
Ischemia
TI
RAO, IRBBB N
N
ASMI
C-Meg. general N
TI
N
N
YSO
N
C-Meg. general
RYE
N
N
N
N
N
N
N
N
C-Meg. general
RYE
Pain and OWC Pain
N N
N
LASH, ST-T IRBBB
YT(off quinidine)
N
N
Paradox septum Paradox septum N
Paradox septum
N
N N
N N Pain and OWC N
N
The mean follow-up time for the group was 25 months, and the range was 7 to 60 months. All patients at the time of interview had one or more cardiac-like complaints. Physical examination and laboratory testing revealed residual abnormalities in all but one pa-
N N
Ab
YSO
N N
RY Enlarged
N
Yes
Postoperative coronary angio., circumflex disorder
Postoperative coma, I~ mo.
Psychotherapy
Catheterized twice; 2: I L-R shunt, YSO and YO
Postoperative YF
tient. The abnormalities were often multiple, but no abnormality correlated with the injury (Fig. I). Three patients (Nos. 3, 13, and 15) had an obvious murmur of triscupid insufficiency, one (No. 2) had aortic insufficiency, one (No. 16) had a ventricular septal de-
5I4
The Journal of Thoracic and Cardiovascular Surgery
Abbott et at.
Patients
rmal 90%
8
4
o
Work Capacity
Working
Cardiac Complaints
Fig. 2. Physiological work capacity, cardiac complaints, and post-trauma employment status in 20 survivors of penetrating cardiac wounds. The dotted line in the workingcolumn separates those who were unemployed before injury (two patients) from those who were employed (18 patients). feet, and one (No .7) had a functional basal murmur. Only seven patients had no electrocardiographic abnormalities. A healed myocardial infarction was obvious on the electrocardiograms of three patients (Nos. I, 4, and 14); in each, the electrocardiographic hallmarks were present on the immediate postoperative electrocardiograms, although this fact was not appreciated by the attending staff at that time because of the concomitant changes of acute pericarditis. An electrocardiogram obtained in one of these three patients (No. 14) during a routine health examination 2 months before the cardiac injury showed no evidence of infarction or other abnormalities. Five patients (Nos. 2, 6, 9, II, and 18) had nonspeci fie abnormalities of the ST-T wave on the resting electrocardiogram that were probably residual effects of the trauma-associated pericarditis. Five patients (Nos. 3, 8, 12, 18, and 19) had abnormal axis deviations or conduction defects or both. Another (No . 20) had asymptomatic bursts of ventricular tachycardia that were easily suppressible with quinidine . Seven patients (Nos . I, 4, 8, 10, 13, 16, and 19) had roentgenographic evidence of cardiomegaly: The right side of the heart was enlarged in one (No.8); the left side of the heart was enlarged in another (No.4); and the entire heart was enlarged in five. All of these
seven patients had abnormal radioisotopic angiograms or echocardiograms. However, over-all there was poor correlation of chamber abnormality among roentgenogram, radioisotope angiogram, and echocardiogram. The acquired ventricular septal defect noted during the physical examination of Patient 16 was apparent on a radioisotope angiogram. The location and magnitude of the defect were determined during two post-traumatic catheterizations of the heart performed 9 months apart, the last one conducted I year after the injury. Both of these studies documented a ventricular septal defect high in the septum, the presence of a left-to-right shunt with the pulmonary blood flow twice that of systemic blood flow, and a small diverticulm of the left ventricular wall in the area immediately opposite the traumatically produced ventricular septal defect. There was no change in the magnitude of the shunt or enlargement of the diverticulum between the studies. The patient was asymptomatic, re-employed, and had a normal electrocardiogram and normal ventricular wall motion. The most common echocardiographic abnormality was paradoxic motion of the interventricular septum, which was present in eight patients (Nos. 1,4,8,9, 10, 13, 14, and 20). This was associated with right ventricular enlargement in two (Nos . 4 and 8) and was associated with electrocardiographic evidence of a remote anteroseptal myocardial infarction in three (Nos. I, 4, and 14). One patient (No . 20) had bouts of ventricular tachycardia but never during the echocardiography . Interventricular septal hypokinesis was present on the echocardiogram in Patient I I. Results of graded treadmill stress testing were within normal limits in 14 patients and abnormal in six. In three patients (Nos. 14, 18, and 19) stress-induced chest pain developed that was atypical of angina and was not accompanied by ischemic electrocardiographic changes. All three had normal myocardial radioisotope scans during exercise, and their symptoms were considered nonischemic in origin. Two of these three (Nos . 14 and 18) had a decreased age-predicted peak functional capacity, but the exercise levels they achieved were in excess of their pretrauma work requirements; Patient 19 was unemployed prior to his injury. Two other patients (Nos. 5 and II) had no cardiac symptoms during exercise and reached target heart rates, but stress-induced electrocardiographic changes occurred . Patient II had a normal myocardial scan, and Patient 5 had no abnormalities during a preinjury stress test given as part of a routine physical examination. This patient's postinjury myocardial scan was also normal, but a subsequent coronary angiogram revealed a significant lone
Volume 75
Penetrating cardiac wounds
Number 4 April,1978
5 15
100
80 w
ell:
o U
V>
~
tJJ
40
I-I" I -
I.R.l07
Q--1[---Q--~I--~~-Q ']:.. .
~-1
I.R.90
20 OL..-----:-'-------'----'-------'---...L.------l._--'----_L..-----'--_...L.------l._ _
Fig. 3. The Minnesota Multiphasic Personality Inventory T scales reveal significant differences and trends between the 20 recovered cardiac victims (solid line) and 19 control subjects (dotted line). The internalization ratio (I.R.) is indicated on the right and is significantly higher in the victims (107) than in the control subjects (90). lesion in the cirumflex coronary artery. The exerciseinduced electrocardiographic abnormalities in both of these patients could have been residual effects of the post-traumatic pericarditis. In one patient (No. I) atypical angina-like pain developed and ischemia was apparent during a myocardial radioisotope scan at work levels greater than those required by his job; this patient also had a healed anteroseptal myocardial infarction. He probably has coronary disease, although he related the onset of his symptoms to the traumatic injury. Twelve patients were unemployed after their injury (Fig. 2). Neither of the two victims (Nos. 2 and 19) who did not work prior to injury worked after the injury. Six patients (Nos. 3, 5, 9, II, 17, and 18) had excessive chest pain when they returned to their previous employment duties and therefore were unable to resume employment. Two patients (Nos. 13 and 14) noted excessive fatigue when they attempted to return to their jobs and therefore retired prematurely. One patient (No. 10) had mild permanent neurologic damage as a result of his wounds and could not perform his prior duties as a cook. Patient 8 was excessively anxious and reported that his heart could not withstand the stresses of his previous employment and therefore remained unemployed. All 10 of these patients who did not resume their jobs after injury had exercise stress tests that documented physiological ability to perform
work levels at or in excess of their preinjury work levels without untoward cardiac abnormalities. Only two of the five patients who refused testing but whom we contacted via telephone or friends had returned to work. The other three who had previously been employed expressed continued anxiety about their cardiac wounds and related their failure to return to gainful employment to their injury. Nineteen of the patients received no psychological evaluation or therapy during or after hospitalization. One patient (No. 12), whose wound was sustained in an attempted suicide, underwent I year of posthospitalization psychotherapy. Our psychologic testing revealed that four patients, including Patient 12, had normal results, but 16 patients had abnormal psychological indexes. The results of the psychological tests of the recovered victims of cardiac wounds are compared with those of the 19 control subjects (hospital employees) in Fig. 3. Hypocondriasis, compulsiveness, and internalization were significantly greater (p < 0.05) in the recovered victims. These symptoms are commonly associated with a neurotic state. The tests for the cardiac patients also demonstrated depression, hysteria, psycopathic deviation, and schizophrenic behavior more frequently than those for the control subjects, but the difference was not statistically significant. Two of the cardiac patients had abnormally
The Journal of
5 I 6 Abbott et al.
high lying or cheating scores; thus their psychological data were excluded from analysis. Comparison of the psychological tests of our patients with the 17 patients who had recovered from major traumatic gunshot or stab wounds of the abdomen revealed similar results in every detail with no significant differences. We therefore attributed the abnormal psychological results to the traumatic experience and not specifically to cardiac trauma.
Discussion Previous reports of victims survivmg penetrating cardiac wounds emphasized the high incidence of chronic psychological disability in such patients. Steffens" in 1936 reported a two-decade follow-up of 109 veterans of World War I with healed bullet wounds of the heart. Only 13 percent of the veterans were free of symptoms; the remainder had complaints that were considered by Steffens to be psychogenic rather than physicogenic. Bland and Beebe!" reported a 20 year follow-up of 40 World War II veterans with retained missiles in the heart. They emphasized the low frequency of physiological disability. Indeed, only two of the patients had severe valvular insufficiency. However, 17 patients had cardiac-like symptoms and frank anxiety was identified in seven. Five of these seven were unable to work. Noth!' reported cardiac symptoms in all 14 survivors of penetrating cardiac wounds treated at a civilian hospital. He attributed the symptoms to neurosis in each case. These three reports implied that the psychological neurosis of the patients was attributable to the fact that the heart was the organ affected. None of the studies contained detailed psychological information nor was objective psychological testing performed. Our study is unique in that we performed both objective psychological and physiological tests and compared our survivors with survivors of major life-threatening traumatic wounds of other organs and with control subjects with socieconomic backgrounds similar to those of our patients. These comparisons revealed that the psychological abnormalities in our patients were secondary to the traumatic episode and were not unique to those suffering cardiac trauma. Thus if neurosis develops after a penetrating cardiac wound, it probably is strictly a traumatic neurosis, the dynamics of which are well known. 12 The syndrome results from any injury causing great fright. The fright may result in long-lasting, if not permanent, anxiety and dependence that are often associated with a multitude of somatic complaints without identifiable organic cause. Patients with traumatic neurosis frequently do not function normally socially and the per-
Thoracic and Cardiovascular Surgery
manent unemployment rate is high. The chronicity of the syndrome is directly related to the lack of prompt postinjury psychological therapy;" Symbas and associates'" reported 16 cases of delayed cardiac sequelae in 56 patients followed for 6 to 19 months after sustaining a penetrating cardiac wound. There was a high frequency of shunts between cardiac chambers of great vessels, valve lesions, and traumatic ventricular aneurysms. However, he did not detail the functional impairment of the 16 patients. Syrnbas" emphasized the need for follow-up surgical repair if such lesions were of frank hemodynamic significance or if a traumatic ventricular aneurysm were discovered. Only one (No. 16) of our survivors has required subsequent surgical repair; he had a hemodynamically significant ventricular septal defect that did not close and a traumatic diverticulum of the left ventricle. Other investigators also emphasized the need for definitive surgical correction in some patients with traumatic cardiac lesions.l'"?" Heller and co-workers" reported on 27 patients from an urban general hospital who suffered traumatic cardiac wounds. They emphasized early cardiac sequelae with these injuries. They specifically identified the early postoperative electrocardiographic abnormalities and documented the presence of acute pericarditis in all victims. In addition, they noted a high frequency of pericardial tamponade, conduction defects including complete heart block, and electrocardiographic evidence of myocardial infarction. Cardiac murmurs from either ventricular septal defects or presumed tricuspid or aortic insufficiency developed in six of their patients. However, the follow-up time was short because many of the patients were lost to follow-up, and thus only fragmentary and anecdotal information was available regarding the functional capacities of the patients. Other investigators also reported the high frequency of electrocardiographic abnormalities, namely pericarditis, conduction defects, and myocardial infarction, in survivors of cardiac trauma. II, 20 However, the results of the extensive physiological tests in our patients provide greater information about the extent of physiological recovery from traumatic cardiac wounds. Only one of our patients (No. 17) had completely normal physiologic test results. Most survivors had readily identifiable physiological deficits. Eight patients had frank valvular leaks, a hemodynamically significant ventricular septal defect, or myocardial infarction. Six had paradoxic or abnormal motion of the interventricular septum, which has not been described heretofore. We are uncertain of the cause of this disorder, but a similar phenomenon was observed in patients after cardiac bypass and was
Volume 75
Penetrating cardiac wounds
Number 4 April,1978
attributed to pericardiotomy. 21 Pericardiotomy was performed in all six of these patients, and this, rather than a conduction defect or myocardial depression, could be the cause of the abnormal motion. Persistent ventricular ectopia that required months of treatment with an antiarrhythmic agent was present in one (No. 20) of our patients. This phenomenon has not been reported previously in patients with cardiac wounds; its origin is unclear. Some of the abnormalities that we identified were probably present at the time of or immediately after the initial injury. For example, in three of our patients the diagnosis of myocardial infarction was not made at the time of surgical recovery, although review of the postoperative electrocardiograms revealed its presence in each patient. The electrocardiographic abnormalities probably were falsely attributed to coexistent changes of acute post-traumatic pericarditis. However, the only murmur immediately obvious at the time of injury was in the victim with the ventricular septal defect. Ten of our patients who previously had been productive members of society tried to resume employment unsuccessfully. Graded exercise testing proved that only two (Nos. 12 and 14) of the ten had decreased physiological functional capacity that clearly required them to alter their postinjury stress but not their work activities. In the remaining eight, exercise capacity was not abnormal and unemployment was related to psychological abnormalities. An undiagnosed and untreated traumatic neurosis proved to be the major impediment to re-employment. This suggests that a more vigorous emphasis should be placed on the psychological rehabilitation of the survivors of a penetrating cardiac wound, which should probably begin during hospitalization. This is perhaps corroborated by the case (Patient 12) in which psychotherapy was initiated immediately because the wound was sustained in a suicide attempt. The patient had a normal psychological profile at the time of testing and was re-employed. We recommend that changes in the management of patients recovering from penetrating cardiac wounds be implemented. Specifically, victims of such wounds should be followed systematically by both the surgeon and intemist to ensure that victims with myocardial infarctions or serious ventricular arrhythmias receive appropriate treatment. We also recommend that early psychological rehabilitation be carried out to prevent the psychological disabilities identified in our study. Furthermore, victims of a cardiac wound should be assessed for their physiological recuperative potential and then be subjected to a graded stress test after recovery, if only for reassurance. Both physiological and
5 I7
psychological testing allow the surgeon and the internist to define the mechanism of each individual victim's problems and permit a rational approach to long-term management. We thank E. B. Raftery, M.D., of London, England, for performing the physiological testing for Patient 7. Patient 16 is a patient of Donald McDonald, M.D., of Vallejo, California; corrective surgery was performed by Norman Shumway, M.D., of Stanford University Medical Center, Palo Alto, California. REFERENCES
2 3 4
5
6
7
8
9 10
II 12 13 14
15 16
Parmley LF, Mattingly TW, Manion WC: Penetrating wounds of the heart and aorta. Circulation 17:953, 1958 Lim RC Jr: Evaluation and immediate management of open chest wounds. Hosp Med 11:8, 1975 Ebert P: Cardiac injuries (trauma rounds). West J Med 125:85, 1976 Beach PM Jr, Bognolo D, Hutchinson JE: Penetrating cardiac trauma. Experience with thirty-four patients in a hospital without cardiopulmonary bypass capability. Am J Surg 131:411, 1976 Abbott JA, Tedeschi MA, Cheitlin MD: Graded treadmill stress testing. Patterns of physician use and abuse. West J Med 126:173, 1977 Rolston WA, Hirschfeld DS, Emilson BB, Cheitlin MD: Echocardiographic appearance of ruptured aortic cusp. Am J Med 62:133, 1977 Zaret BL, Strauss HW, Hurley PJ, Natarajan TK, Pitt B: A noninvasive scintiphotographic method for detecting regional ventricular dysfunction in man. N Engl J Med 284: 1165, 1971 Strauss HW, Harrison K, Langan JK, Lebowitz E, Pitt B: Thallium-20J for myocardial imaging. Relation of thallium-201 to regional myocardial perfusion. Circulation 51:641,1975 Steffens W: Arbeit und Gesundheit Heft 27. Herzsteckschusse , Leipzig, 1936, Georg Thieme Bland EF, Beebe GW: Missiles in the heart. A twentyyear follow-up report of World War II cases. N Engl J Med 274:1039, 1966 Noth PH: Electrocardiographic patterns in penetrating wounds of the heart. Am Heart J 32:713, 1946 Keiser L: The Traumatic Neurosis. Philadelphia, 1968, J. B. Lippincott Co., p. 35 Rape Victimization Study, Queens Bench Foundation, San Francisco, 1975, p. 79 Symbas PN, DiOrio DA, Tyras DH, Ware RE, Hatcher CR: Penetrating cardiac wounds. Significant residual and delayed sequelae. J THORAC CARDIOVASC SURG 66:526, 1973 Symbas PN: Residual or delayed lesions from penetrating cardiac wounds. Chest 66:408, 1974 Singh R, Nolan SP, Schrank JP: Traumatic left ventricular aneurysm. Two cases with normal coronary angiograms. JAMA 234:412, 1975
The Journal of
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Discussion DR. ROGER R. ECKER Oakland, Calif.
I would like to compliment Dr. Abbott and his co-workers on this very thoroughgoing and careful follow-up of the type of patient that we all see frequently. They are quite correct in saying that most of the physiological abnormalities which they documented were unsuspected. Many of us have seen these patients and, except for an isolated case of valve injury or ventricular septal defect, we seldom recognize any abnormality. Yet, there is a disastrous effect on the social adjustment of the patient, for he is not returning to work and has many fears and depressions. Ever since Ludwig Rehn performed the first successful suture of a cardiac wound in 1897, most surgeons have approached this operation in a similar manner. We are most interested in where the wound is, and the outcome is measured in terms of the surgical mortality rate. We were able to report some years ago from Parkland Hospital on 86 patients who arrived in the hospital with stab and gunshot wounds of the heart. However, it is important to remember that, in the same time period, four times as many patients, 373, also arrived by the back door. In other words, the problem does not begin in the emergency room. It begins at the site of injury, and I think that we may find that something can be done at the scene or quite early, as is done for heart attack victims. The treatment for gunshot and stab wounds of the heart has changed over the years, waxed and waned in favor of pericardiocentesis or surgery. We certainly favor surgery, and
Thoracic and Cardiovascular Surgery
we were able to reduce the mortality rate by an emphasis on prompt surgery. We have dispensed with treatment by pericardiocentesis except as a temporizing procedure. The mortality declined to as low as 5 percent for stab wounds and 24 percent for gunshot wounds or an over-all mortality of 15 percent for patients who arrived in the emergency room alive. We also studied a series of patients who had coronary artery wounds. In the earlier series of stab and gunshot wounds, some patients had coronary artery lacerations. In looking over our data, I found that we made no statement whatsoever about how many patients returned to work. In other words we ignored that aspect altogether. There were 22 patients with coronary artery lacerations, and a good number of them were dead on arrival. Fifteen were alive on arrival, and of the 15, 10 survivors left the hospital. We did follow up the 10 patients with coronary artery lacerations. One of them had a ventricular septal defect which had to be closed, and he went back to running track at his high school. I am sure we did not document the follow-up of the other 9 as carefully as Dr. Abbott, Dr. Thomas, and their colleagues have, but we stated that all returned to their former activities. That may mean fighting in bars, but they were able to return to what they did before. [Slide] This slide indicates the mortality rate from trauma in the United States for 1970. I am sure that the current figure is probably larger. In simply cataloging operative mortality rates from gunshot and stab wounds of the heart and from other trauma, we as thoracic surgeons perhaps are ignoring the larger picture. This study by Dr. Abbott and his colleagues points up another and a very important aspect. There are several other aspects which need to be addressed, such as the out-of-hospital mortality rate. Perhaps we should go on from there to the preventive aspects, to how we can reduce the number of people who are stabbed and shot. That may seem out of the question, but perhaps we can have some impact on it. I would not want to suggest gun control legislation, because that would be very unpopular. However, there may be things we can do in the preventive field. As thoracic surgeons, we should definitely be involved not only in the treatment of these patients to keep them alive, but in their rehabilitation as well. DR. A B BO TT (Closing) I would point out for those interested in the over-all social aspects of violent crimes that there was a Presidential Commission which extensively explored the root causes of violence in our society and which made very pertinent recommendations for prevention ("To Establish Justice, to Insure Domestic Tranquility. The Final Report of the National Commission on the Causes and Prevention of Violence." New York, 1970, Praeger Publishers, Inc.). Unfortunately, most of these recommendations have not been implemented.