PENETRATING CARDIAC INJURIES

COMPLEX AND CHALLENGING PROBLEMS IN TRAUMA SURGERY

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PENETRATING CARDIAC INJURIES Juan A. Asensio, MD, FACS, B. Montgomery Stewart, MD, James Murray, MD, Arthur H. Fox, MD, Andres Falabella, MD, Hugo Gomez, MD, Adrian Ortega, MD, FACS, Clark B. Fuller, MD, and Morris D. Kerstein, MD, FACS

El corazon es un loco que no sabe de un color: 0 es su amor de dos colores, 0 dice que no hay Amor. The Heart is a madman That does not recognize a single color: Either his love is of two colors Or he declares that there is no love. JOSE MARTI Cuban Poet and Liberator

The heart is such a unique organ, so vital and constant in its tireless function, yet so fickle once its never-ending musical rhythms are disturbed. It is never the tired worker, the strong beating never ceasing, yet so romantic in its very reason for existing. No other organ has inspired so many talented poets, writers, and musicians to create sweet and endless poems, alluring novels, and beautiful rhythms. Witness Homer’s poetic description of the death of Sarpedon from the classical Greek epic The Not so Patroclus’ never erring darts; Aim’d at his breast, it peers at the mortal part, Where the strong fibers bind the solid heart. From Los Angeles County/University of Southern California Medical Center, Los Angeles, California (JAA, BMS, JM, AHF, AF, HG, AO, CBF); and the Department of Surgery, Hahnemann University, Philadelphia, Pennsylvania (MDK)

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Th’insulting Victor with disdain bestrode The prostrate prince, and on his bosom trod; Then drew the weapon from his panting heart, The reaking fibers clinging to the dart; From the wide wound gush’d out a stream of blood, And the soul issued in a purple flood. The purpose of this article is to cover in detail all aspects of cardiac injury management, including the controversies generated by the newer diagnostic modalities such as echocardiography versus the gold standard represented by the subxiphoid pericardial window. This article also examines in great detail the topic of emergency department (ED) thoracotomy, along with the technical complexities of the surgical management of these challenging injuries. HISTORICAL PERSPECTIVE

Cardiac injuries have been well described throughout time. The earliest descriptions of cardiac injuries appear in the Iliad, which contains specific references to exsanguination as a cause of death and foreign bodies located within the heart. The death of Sarpedod7 describes an episode of exsanguinating hemorrhage from a cardiac injury (Fig. 1).The records an observation of the cardiac impulse transmitted through a spear that had transfixed the heart of Alkathoos: “The hero Idomeneus smote him in the midst of the breast with the spear . . . and he fell with a crash, and the lance fixed in his heart, that, still beating, shook the butt end of the spear.” Other early descriptions of penetrating chest wounds can be found in the Edwin Smith Papyrus,22 written around 3000 BC. Beck” classifies the history of wounds of the heart according to three historical periods. First, the period of mysticism, in which wounds to the heart were described but were considered to be uniformly fatal. This period extended

Figure 1. The death of Sarpedon illustrated on a Greek vase. (Courtesy of Dernetrios Demetriades, MD, PhD, FACS.)

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into the seventeenth century. This was followed by the period of observation and experiment, culminating in the period of suture, which had its beginning in 1882. Representative examples of the currents of thought in each period are presented below. Hippocrate~~~ stated that all wounds of the heart were deadly. Numerous authors such as Ovid?l Celsus,26 P l i n ~ ?Aristotle? ~ and GalenS3regarded them as absolutely and necessarily fatal. Aristotle stated, “The heart alone of all the viscera cannot withstand serious injury. This is to be expected because when the main source of a strength (the heart) is destroyed there is no aid that can be brought to the other organs which depend on it.“ Galen also noted that when wounds of the heart were observed in gladiators, they were all uniformly fatal. Paulus A e g h ~ e t avery ~ ~ poetically described the venting of a pericardial tamponade: ”When the heart is wounded, the weapon appears at the left breast and feels not as if in a cavity but as fixed in another body, and sometimes there is a throbbing motion; there is a discharge of black blood if it can find vent, with coldness, sweats and deliquium animi, and death follows in a short time.” FallopiusUdescribed the difference between wounds of right and left ventricles when he asserted, ”Wounds of the heart are always followed by sudden death. When wounded it cannot heal, being too firm, always in motion and of an inflammatory heat. Wounds of the right ventricle may be differentiated from wounds of the left ventricle; from the former comes dark blood, and from the latter red blood.” Ambroise Park93described cardiac injuries and their presenting signs in the following statement: ”By these signs you may know that the heart is wounded; if a great quantity of blood gush out, if a trembling possess all the members of the body; if the pulse beat little and faint, if the color become pale, if a cold sweat and frequent sowning assayle him, and the extreme parts become cold, then death’s at hand.” Park94also described in his classic masterpiece The Apologie and Treatise the prognosis of several wounds, including cardiac wounds. “Those wounds are thought dangerous, where in any large nerve, veins, or artery are hurt . . . But they are deadly which are inflicted upon the bladder, brain, heart, liver, lungs, stomach and small guts.” Furthermore, he described the autopsy results of a stab wound to the hearF9:“At Turin I saw a gentleman who fought with another who gave him a sword thrust under his left breast penetrating the substance of the heart. He did not cease, but struck his enemy with many thrusts until he fled. He pursued him a distance of two hundred paces, then fell dead. While making an autopsy, I found a wound in the heart substance large enough to admit a finger and a large amount of blood on the diaphragm.” Fabrici~s?~ in the following statement, ”If the heart is wounded the affair is desperate, so also, if the pericardium is wounded. It is, therefore, unnecessary to attempt any.treatment,” summarized the frustration of attempting to manage any of these injuries. BoerhaaveI9believed that ”All wounds of the heart deep enough to penetrate into either of the ventricles are mortal.” This period, which was characterized by acceptance of the inevitability of demise of any cardiac injury while romanticizing them with poetic statements, gave way to the period of observation, which was defined by scientific challenges issued to the ancient wisdom that all cardiac wounds are fatal. Thus, in the seventeenth century, the stronghold of these firmly entrenched concepts was broken by Hollerius,65who was the first to advance the idea that wounds of the heart can heal and are not all necessarily fatal. in 1642, was the first to describe a healed wound of the heart. This description remained forgotten for over a century until Senaclosconcluded in 1749 that all wounds of

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the heart are always serious, although a penetrating wound may heal and may not be fatal. In 1761 MorgagnP' made a classic observation that alerted physicians to the dangers of compression of the heart due to hemorrhage into the pericardium. He noted that a puncture of a coronary artery on the external surface of the heart might cause hemorrhage into the pericardial sac, with subsequent compression in the rest of the heart. Larrey7*in 1810 described the case of a 30year-old man with a self-inflicted stab wound on the left side of the chest: "The stab wound had passed through the fifth intercostal space and the knife was still lodged as the patient was brought into the hospital." A classic description of the clinical presentation of pericardial tamponade then follows: "The pulse was rapid and there was grave dyspnoea. Bleeding gave some relief." The patient requested Larrey either to open his chest or to give him a narcotic strong enough to send him to sleep. The operation took place 45 days after the injury and was described as

. . . an incision through skin and cellular tissue in the fifth nipple, carefully carried deeper until pericardium was felt. With the left index finger on the pericardium as a guide, an incision into the pericardium was made with a bistoury, the finger inserted, and the apex of the heart felt. About a liter of fluid with some blood clot escaped. Great relief. In ten days the wound closed and the symptoms recurred. Wounds reopened with a probe, four ounces of pus escaped. Considerable improvement. Death sixty-eight days after injury twenty-three after operation. Autopsy: Suppurative mediastino-pericarditis. Larre~ also ~ ~described the surgical approach to the pericardium: In a pericardial effusion . . . I should carry out the operation at the most dependent point of the pouch formed by that membrane, and this point, which may be termed the seat of election, corresponds, as we have said, to the interval between the left side of the base of the xiphoid and the united ends of the seventh and eight left costal cartilages. It is in this triangular cellular space that an oblique incision may confidently be made from the junction of the seventh costal cartilage with the sternum along its inferior border as far as the end of the eight costal cartilages, which is closely united by fibrous tissues to the seventh costal cartilage. In this incision, which divides some fibres of the first digitation of the rectus and of the external oblique, is included the lamellar fibrous tissue which is continuous with that which is called the false layer of the peritoneum, on division of which the prominent point of the pericardium, appearing in the interspace among the first two digitations of the diaphragm, is encountered. The point of the bistoury carried carefully upwards and a little from the right to left will enter the pericardium without opening the peritoneum. A small portion of the inferior border of the diaphragm is just cut as it is attached to the posterior surface of the seventh cartilage. No important vessel is met with. Thus this operation, easy to execute, is of all the methods the least likely to wound the heart, and offers the greatest chances of success. L a r r e ~added ~ ~ in a footnote: "The patient should be seated on the edge of

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his bed and should have something to lean against, because in this perpendicular position the inferior border of the base of the pericardium is more inclined forwards, and in consequence, more accessible to the instrument.” In 1829 Larrey” reported a patient whom he treated by passing a catheter into a stab wound of the chest. Three beakers of wine-colored fluid were obtained after the passage of this catheter. Subsequently a sound was passed in the same direction, obtaining four more beakers of similar fluid. This, according to Larre~,7~ was the first case of a wound of the pericardium in which the patient recovered. Other therapeutic maneuvers in the management of cardiac wounds during the first half of the nineteenth century consisted of placing the patient in absolute quiet, applying of leeches, performing venesection, and passing catheters or sounds into the wound with the hope of evacuating fluid from the pericardial cavity. D ~ p u y t r e nwas ~ ~ a strong advocate of venesection. Jobert” in 1839 made the astute observation that the life span of a cardiac wound is directly related to the quantity of blood lost and particularly related to the amount of blood contained in the pericardium. He noted that blood, unable to escape from the pericardium, compresses the heart and decreases cardiac motion until severe loss of cardiac action occurs. This period was also characterized by the appearance of numerous case reports in the literature. For the first time attempts were made to tabulate these cases, studying and analyzing their clinical presentations and carrying out postmortem studies. Purple100in 1850 compiled a total of 42 cases. Fischef19in 1868 was able to collect 452 cases with a 10% survival rate. It was precisely during this time that resistance to any attempt to repair cardiac wounds emerged from no less prominent a figure in the European stage of surgery than Billr~th,’~ who in 1875 expressed in very strong words his views regarding cardiac injuries: ”Paracentesis of the pericardium is an operation which, in my opinion, approaches very closely to that kind of intervention which some surgeons would term a prostitution of the surgical act and other madness.” Regardless of the pronouncements of such a powerful figure, Roberts‘” in 1881 suggested the possibility that cardiac injuries could be sutured but did not attempt to do so. The period of a suture had its beginning in the animal experiments by Block,I7who in 1882 in a rabbit model created cardiac wounds and was successful in suturing them, thus demonstrating the successful recovery of the animals and suggesting that the same techniques could be applicable in humans. Once again, Billroth,13 for reasons unknown, proclaimed his opposition to cardiac injury repair. In 1883, in what is perhaps one of the strongest statements of opposition ever found in the surgical literature, Billroth pronounced at a surgical meeting: “The surgeon who should attempt to suture a wound of the heart would lose the respect of his colleagues.” Another famous statement attributed to BillrothI4 regarding his views upon this subject is: ”Let no man dare to operate upon the heart.” Although Lillehei76has attempted to elucidate the veracity of these quotations by citing renowned Billroth scholars such as Wangensteen and Absolon, these quotations appear from multiple sources and with great frequency in the literature and may be accurate. Whether they can indeed be attributed to Billroth or not awaits further scholarly study, but it seems certain that he expressed strong opposition to cardiac injury management. Riedingerlo2in 1888 wrote, “The suggestion to suture a wound of the heart, although made in all seriousness, scarcely deserves notice.” Paget?* in 1896, in his classic volume entitled The Surgery of the Chest, devotes an entire chapter to the management of wounds of the heart. He begins that chapter with this most fatalistic of all statements, “Surgery of the heart has probably reached limits set by nature to all surgery. No new method, and no new discovery, can overcome

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the natural difficulties that attend a wound of the heart. It is true that heart sutures have been vaguely proposed as a possible procedure, and has been done on animals: But I cannot find that it has ever been attempted in practice.” Fortunately, statements of this nature did not deter Del Vecchio,”’ who experimentally was able to demonstrate cardiac injury healing after suturing in a canine model. The first attempt at repairing a cardiac injury was carried out by CappelenZ5 on September 4, 1896, in Christiania, Norway. He repaired a laceration of the left ventricle and ligated the distal left anterior descending coronary artery successfully. However, the patient did not survive. In March 1896, in Rome, made a second attempt to suture a human heart wound of the left ventricle unsuccessfully. Success awaited the attempt by Rehn’O’ of Frankfurt, Germany, who on September 9, 1896, was successful in repairing a wound of the right ventricle, resulting in a patient’s survival. This event marked the beginning of cardiac surgery. For the first time surgeons had successfully repaired a cardiac injury in a living heart. The reaching of this landmark, which in fact gave birth to the field of cardiac surgery, was followed by an explosion of techniques that were to be applied in the management of cardiac injuries. Remarkably enough, the median sternotomy, one of the most widely used incisions in cardiac injury management, was described by D~va1.~’ In 1897 he described it initially as a median thoracolaparotomy. The skin incision extends from the level of the second interspace to the mid point between the umbilicus and xiphoid. The xiphoid may either be removed or separated in both sides from its ligaments and aponeuroses. The underlying structures are freed from the sternum, and a spatula is inserted beneath to protect the heart. The sternum is split longitudinally with a saw or bones shear to the level of the second or third intercostal space where it’s cut across, care to be taken to avoid the internal mammary vessels. The sternum is retracted, and the pleura is dissected laterally with a moist sponge. The peritoneum is open and the anterior portion of the diaphragm is incised. The pericardium is opened widely, the incision extending to its reflection in the diaphragm. An excellent exposure of the heart is obtained. The ingenuity needed to overcome the surgical inabilities in draining and restoring negative intrathoracic pressure after opening the chest resulted in the development of different surgical approaches to the heart. This included the quadrangular flap with an external hinge which included two to five cartilages, developed in 1900 by Fontan5” from France. American surgical leadership emerged on September 14,1902, when Hillh2of Montgomery, Alabama, became the first American surgeon to successful suture a cardiac injury and the first to successfully repair a left ventricular wound. This case was remarkable in that this operation was performed by the flickering lights of kerosene lamps on an old kitchen table. Most unfortunately, the accomplishments of two Americans surgeons who first repaired wounds of the pericardium did not surface until much later. Credit should be given to Dalton?”of St. Louis, who on September 6, 1891, successfully repaired a wound of the pericardium. Even more remarkable was the accomplishment of Williams,”Rwho on July 9, 1893, successfully sutured a pericardial laceration in a patient who had sustained a stab wound that penetrated the substance of the myocardium. Because the myocardial wound was not bleeding,

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it was not sutured. This accomplishment remained obscure, perhaps because neither surgeon described his operation in the literature until some years later. In the case of Williams, it was because he was an African-American surgeon laboring in an African-American hospital. Some purist surgeons complained that the pericardium was not the heart. To quote Lillehei, ”The paramount fact is that more than 90 years ago two surgeons independently had the courage of their convictions, and ventured into a totally unchartered territory. There is glory enough for both, and with their work, cardiac surgery made its first beginnings, particularly in America.” In 1906, Spangaro”O described the left anterolateral thoracotomy, today’s incision of choice for emergency access to the left hemithoracic cavity. He described this incision as an intercostochondral thoracotomy. The incision is made in the left fourth intercostal space extending from the anterior axillary line to the sternum, where it is continued in each direction along the margin of the sternum to expose the third, fourth, fifth, and sixth costal cartilage. These costal cartilages are sectioned; the internal mammary vessels are ligated, and the incision is extended though the underlying muscles into the pleura. These structures are retracted and the pericardium is opened. The left lung, the left ventricle and part of the right ventricle are exposed. Part of the right ventricle and the base of the heart, including the auricles, are not exposed. The transverse sinus and the vena cava are inaccessible. The control of hemorrhage by compression of this structure therefore, cannot be carried out when this exposure is used. The exposure is sufficient, however, to permit direct compression of the ventricles in the grasp of the operator. Sauerbruch106in 1907 described the method for controlling hemorrhage from a wound of the heart by obstructing flow of blood by compression of its base. “With the right hand the apex of the heart is displaced anteriorly while the third finger of the left hand is inserted through the great transverse sinus, and the fourth and fifth fingers are placed posteriorly in the pericardial cavity. Included between the third and fourth fingers are the venae cavae with a part of the right auricle and the pulmonary veins. By compression of these structures the flow of the blood into the ventricles can be controlled. The thumb and index finger of the left hand are free to steady the heart while the wound is sutured” (Fig. 2). Mata~,7~ a surgeon of Spanish ancestry born in the United States, warned of the dangers of rapidly relieving pericardial tamponade, resulting in exsanguinating hemorrhage. In 1909 described a patient with a stab wound to the right atrium who survived, and he reviewed the world’s literature on cardiac injuries. Peck disputed the excessive mortality attributed to wounds of the auricles, which were considered by most surgeons to be more lethal than ventricular wounds. In this review of the literature he reported 11 cases, 7 of which survived with a mortality of 36.3%. also reported the combined mortality of all cardiac wounds as 64%. In addition, he described a comprehensive surgical approach that consisted of anesthesia, local preparation of the operative field, choice of method of exposure, temporary control of hemorrhage during suturing, and, finally, stimulation and resuscitation. In this study he also described techniques of cardiorrhaphy that are still widely used today. At the same time he pointed to the need for expediency in executing the aforementioned operative plan.

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Figure 2. Sauerbruch’s maneuver.

in 1912 collected additional cases to be added to Peck’s series and further described surgical techniques in the management of cardiac injuries, concluding that: ”The treatment of heart wounds should be surgical.” He also recommended that in suspected wounds of the heart, when the diagnosis is probable but not positive, exploration should be performed. In this study he also described and analytically criticized the different surgical approaches and quoted Borchardt,2O who provided supporting evidence that ”the classical heart syndrome of tamponade, due to elevated intrapericardiacpressure is more often absent than present.” Surgeons during the early part of the century preferred to approach the heart extrapleurally to minimize the dangers of pneumothorax; such extrapleural approaches were time consuming. recommended the use of positive pressure ventilation during anesthesia to prevent pneumothoraces and thus permit a rapid transpleural approach to the heart. Furthermore, in this paper he described the use of a fine Vaselined silk as a suture of choice and defined the indications for pericardial drainage. Ballance5 in 1920 delivered the Bradshaw lecture on surgery of the heart, which to this date remains one of the most comprehensive treatises in cardiac injury management; in it he summarized the currents of thought present in the surgical literature of that time. Smithlogin 1923 developed a comprehensive plan for cardiac injury management and for the first time pointed out the dangers of dysrhythmias during cardiac manipulation. He also described the use of an Allis clamp near the apex to stabilize and hold the heart while sutures were being placed and also to displace it out of the pericardium to inspect its posterior surface. Similarly, Smith tabulated and analyzed the mortality of cardiac injuries according to the chambers injured. Beck” in 1926 described the physiology of cardiac tamponade and reported the results of his animal studies. He described the clinical symptomatology of pericardial tamponade, the triad that now carries his name. Furthermore, he analyzed the historical developments of cardiac injury management throughout history in a most superb paper while describing comprehensively some of the techniques that are still in use today. He advocated placing an apical suture to hold the heart under gentle traction prior to placement of the definitive sutures to effect the repairs.

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Similarly, S~hoenfeld'~~ in 1928 and BiggerI2in 1939 reported their collective experiences in the management of cardiac injuries. Elkinj8in 1941 recommended the use of fluoroscopy to assess cardiac motion and alerted surgeons to the dangers of icepick injuries while describing the advantages and disadvantages of the median sternotomy and the left anterolateral thoracotomy incisions. Furthermore, he described the use of a clamp to control hemorrhage from atrial wounds. Beckloin 1942 pointed to the necessity of a sparing ligation of coronary arteries in wounds adjacent to these structures and recommended the use of mattress sutures placed underneath the bed of coronary arteries. Turner1I6in 1942, after reviewing the experience with cardiac injury management during World War I, pointed to the need for the emergency treatment of cardiac injuries, particularly those caused by shell fragments. G r i s ~ o l din~ ~ 1942 described his experience and pointed to the cause of death from cardiac injuries as either exsanguination or tamponade. He recommended rapid intravenous fluid administration, particularly blood, but believed that this was of little help in the management of pericardial tamponade, pointing instead to the need for aggressive repair of the injury. He described refinements of techniques to manage cardiac injuries and recommended placement of a small patch of pectoral muscle to cover partially transected coronary arteries. Griswold's most important recommendation advocated that "every large general hospital should have available at all times a sterile set-up of instruments and linens, and the operating room with at least one nurse and orderly in attendance, to be open twenty four hours a day."58This more than anything else helped to set the stage for the development of modern-day trauma centers. Blalock and Ravitch16 in 1943 described the use of pericardiocentesis for the management of cardiac injuries in American soldiers during World War 11. They proposed nonoperative management of these wounds. They made the observation that some wounds of the heart may seal and stop bleeding on their own. This treatment was advocated in the hope of decreasing the high mortality of these injuries. Their protocol included aspiration of blood from the pericardium by the costoxiphoid route, with one further attempt in case of recurrence, and finally, cardiorrhaphy for a second recurrence. This became the standard treatment for many cardiac injuries during World War 11. Elkinj9 in 1944 recommended the administration of intravenous infusions prior to operation and pointed to the beneficial effects of increasing blood volume and thus cardiac output. Harked0 in 1946, drawing upon his experience in the management of thoracic injuries during World War 11, described techniques to remove foreign bodies adjacent to the heart and major blood vessels. This remarkable review of history brings to light many ingenious and daring contributions, which form the basis of the surgical armamentarium that modern-day trauma surgeons possess to deal with these injuries. Today, in many urban trauma centers, surgical residents routinely perform ED thoracotomies and cardiorrhaphies, along with complex cardiac repairs, with little reflection that this year marks the one hundredth anniversary of the first successful repair of a cardiac injury. CLINICAL PRESENTATION OF CARDIAC INJURIES

Beck's triad represents the classic presentation of a patient arriving in an ED with a full-blown pericardial tamponade. Kussmaul's sign, described as jugular Venus distention upon inspiration, is another classic sign attributed to pericardial tamponade. In reality, the presence of Beck's triad or Kussmaul's

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sign represents the exception rather than the rule. In general, penetrating cardiac injuries can be extremely deceptive in their clinical presentations: Patients may present with penetrating injuries located in the precordium or their injuries may be found in an extraprecordial location. Most wounds located in the precordium are generally stab wounds, whereas gunshot wounds can damage the heart from both a precordial and an extraprecordial location. Thoracoabdominal injuries can be quite lethal, and the heart can be affected as well as many other organs. Hirschberg et aP4 (Fig. 3 ) described the lethality of thoracoabdominal wounds in their series of 82 patients with 21 associated cardiac injuries. The clinical presentation of penetrating cardiac injuries ranges from complete hemodynamic stability to acute cardiovascular collapse and cardiopulmonary arrest. Their clinical presentations can also be related to several factors, including the wounding mechanism; the length of time elapsed prior to arrival in a trauma center; the extent of the injury, which, if sufficiently large, causes exsanguinating hemorrhage into the left hemithoracic cavity; whether blood loss exceeds 40% to 50% of the intravascular blood volume, resulting in cessation of cardiac function; and whether a pericardial tamponade is present or absent. Patients sustaining high-velocity missile injuries with massive tissue destruction; patients who arrive late in a trauma center, having experienced cardiopulmonary arrest for prolonged periods of time; and those who have lost the majority of their blood volume into the left hemithoracic cavity invariably develop cardiopulmonary arrest with little chance for survival. Others present as hemodynamically stable after sustaining penetrating injuries to the heart. It is well known that the muscular nature of the left ventricle and to a smaller extent the right ventricle can and often does seal and prevent exsanguinating hemorrhage, allowing these patients to arrive alive at a trauma center (Fig. 4). Pericardial tamponade is a unique manifestation of cardiac injury. The fibrous nature of the pericardium renders it relatively inelastic and noncompliant to any sudden increases in intrapericardial pressure. Sudden acute losses of intracardiac blood volume lead to acute intrapericardial rises of pressure and compression of the thin-walled right ventricle. This decreases its ability to fill,

Figure 3. Thoracoabdominal injury. This patient sustained a left ventricular laceration along with lacerations of the gastroesophageal junction, diaphragm, and spleen from a single

gunshot wound.

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Figure 4. Gunshot wound in the left ventricle. The myocardial muscle sealed the laceration temporarily, allowing the patient to undergo a definitive repair and survive.

resulting in a subsequent decrease in left ventricular filling and ejection fraction, thus effectively decreasing cardiac output and stroke volume.z9Cardiac work also increases, as does myocardial wall tension, increasing energy demands on the heart which, owing to its increased work load, has already developed a greater oxygen demand that cannot be met, resulting in hypoxemia, oxygen debt, and lactic The pericardium is able to accommodate gradual accumulations of blood if the bleeding is not rapid enough to cause acute rises in intrapericardial pressures which exceed the right ventricle’s and, subsequently, the left ventricle’s ability to fill.”, 40 A slow and gradual bleed is better tolerated, as it can be gradually accommodated by the pericardium. This may explain why some patients are hemodynamically unstable with pericardial tamponade caused by smaller volumes (Fig. 5 ) and others are totally stable with relatively large volumes of blood and clot within the pericardium (Fig. 6 ) . It is clear that pericardial tamponade can have both a deleterious and a protective effect. The deleterious effect can lead to a relatively rapid cardiopul-

Figure 5. Pericardial tamponade caused by a small quantity of blood and clot.

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Figure 6. Pericardial tamponade caused by a large quantity of blood and clot. The clot was located posteriorly in the pericardium.

monary arrest. Its protective effect can limit extrapericardial bleeding into the left hemithoracic cavity, preventing exsanguinating hemorrhage and allowing the patient to reach the trauma center alive, although with some degree of hemodynamic compromise, to undergo a life-saving procedure. Moreno et a P strongly support the presence of a pericardial tamponade as a critical determinant for survival in penetrating cardiac injuries. In this series, the authors reviewed 100 consecutive unselected patients presenting with acute cardiac injuries; 57 sustained stab wounds and 43 gunshot wounds, and 77 patients presented with pericardial tamponade. Overall, 31”/0survived, including 27 (47%) of 57 patients with stab wounds and 4 (9%) of 43 with gunshot wounds. To analyze whether tamponade was a critical determinant for survival, the patients were stratified according to injury mechanism, wound site, vital signs when presenting in the ED, and the presence or absence of pericardial tamponade. In this study the authors concluded that patients with tamponade experienced a survival rate of 73%, compared with an 11%survival rate in those without its protective effect. The presence of tamponade improved survival following stab wounds-77% versus 29%; gunshot wounds-57% versus none; right heart wounds-79% versus 28%; left heart wounds-71% versus 12%; and overall in patients arriving with vital signs-96% versus 50%. These findings were statistically significant, leading the authors to conclude that pericardial tamponade is a critical independent factor in patients’ survival, and suggested that it may be more influential than presenting vital signs in determining outcomes. Buckman et al,24 in a study of 66 penetrating wounds of the heart, could not find pericardial tamponade to be a critical independent factor in survival. Similarly, Asensio (unpublished data), in a study of 97 patients subjected to ED thoracotomy, did not find pericardial tamponade to be a critical independent factor in survival. Asensio and Demetriades (unpublished data) also, in a prospective 1-year study of 60 penetrating cardiac wounds with an overall survival of 37% and a 16% survival for all patients undergoing ED thoracotomy, did not find, after statistical analysis, pericardial tamponade to be a critical independent factor in survival.

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What is clear is that, despite the differences between these studies, the answer lies somewhere in between: there appears to be a period of time in which pericardial tamponade provides a protective effect and thus leads to an increase in survival rates. What remains undefined is that period of time, after which this protective effect is lost, resulting in an adverse effect on cardiac function. METHODS OF EVALUATION Subxiphoid Pericardial Window

The original technique to create a pericardial window was described by Larre~ in~the ~ 1800s. Remarkably enough, only small variations in the original technique have been added to this procedure. Any patient who sustains a penetrating injury in an area inferior to the clavicles, superior to the costal margins, and medial to the midclavicular lines should be suspected of harboring an injury to the heart (Fig. 7). This technique evaluates the presence of blood in the pericardium; it is indicated for penetrating trauma in proximity to the heart and is considered to be simple and safe. However, inexperienced surgeons often mistake the central tendon of the diaphragm for the pericardium or spend undue amounts of time in performing this procedure. Creation of a subxiphoid pericardial window should be performed in an operating room under general anesthesia. As is routine with all trauma patients, the patient's entire torso is prepped from neck to midthighs. A 10-cm incision is made in the midline over the xiphoid process. This incision is carried through skin and subcutaneous tissue, and hemostasis is achieved using electrocautery. Electrocautery can also be used to dissect directly around the xiphoid. Then, using a combination of blunt and sharp dissection, the xiphoid process is separated, dissected, and grasped by an Allis or Kocher clamp and displaced cephalad; blunt dissection with a Kittner dissector separates adipose tissue beneath the xiphoid. A combination of blunt and sharp dissection after digitally palpating the transmitted cardiac impulse is used to locate the pericardium, which is grasped between two Allis clamps. At that time, if the hemodynamic status allows, the patient may be placed in a reverse Trendelenburg position to allow the pericardium to descend and become more accessible.

Figure 7. Midsternal gunshot wound in a hemodynamically stable patient. There is a positive subxiphoid pericardial window because of a right ventricular laceration.

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A better grasp is usually obtained by replacing the Allis clamps and regrasping the pericardium. Once the pericardium has been firmly grasped and adipose tissue has been cleared away, the surgical area is lavaged with normal saline to remove any blood that may bias the results of the window, and hemostasis is once again checked. Afterwards, a longitudinal incision measuring approximately 1 cm is made in the pericardium sharply, with meticulous care taken not to lacerate the underlying epicardium. After making this aperture, the field is either flooded with clear straw-colored pericardial fluid, signifying a negative window, or with blood, which is indicative of a positive window and thus an underlying cardiac injury. Finally, the field may remain dry if blood has clotted within the pericardium. Many inexperienced surgeons are misled into thinking that no cardiac injury exists given this setting. We recommend passing a suction catheter into the previously made aperture when this situation arises. This move, more often than not, liberates a clot and allows blood to escape through the aperture, in which case the window is positive and the surgeon should proceed to a median sternotomy. Trinkle et in 1974 published a series concerning 45 patients sustaining penetrating injuries to the heart; 21 patients underwent preliminary subxiphoid pericardial window, and 18 were positive and 3 were negative in this series. Eighteen patients also underwent pericardiocentesis, with 7 false negatives and 3 false positives. Although the authors were still in favor of performing pericardiocentesis, they recommended the performance of a preliminary subxiphoid pericardial window under local anesthesia in the operating room. Subsequently, Arom et a14 in 1977, disillusioned with the high rate of false positives and false negatives obtained with pericardiocentesis, studied 50 patients who underwent 50 pericardial windows, 46 of which were positive owing to cardiac or major thoracic blood vessel injuries and 4 of which were negative. They point to one of the causes of high rates of false negatives in pericardiocentesis, which is the presence of a clot in the pericardium, thus rendering the procedure unreliable. Furthermore, in this paper they described the surgical technique and recommended the pericardial window as the technique of choice to evaluate patients with potential cardiac injury. Trinkle et aI1l5in 1979 compared the reliability of pericardiocentesis and subxiphoid pericardial window in a series of 101 patients sustaining penetrating cardiac injuries. Forty-seven patients underwent pericardiocentesis, resulting in 3 false positives (6.4%) and 9 false negatives (19%); of the 54 patients who underwent subxiphoid pericardial windows, 49 were positive and 5 were negative, with no false positives or false negatives. This clearly established the window as the technique of choice for the evaluation of potential cardiac injuries; the authors recommended abandoning the use of pericardiocentesis. Subsequently, Garrison et al,s4in their series of 60 patients with combined thoracoabdominal injuries, described the technique of diagnostic transdiaphragmatic pericardial window to assess for possible cardiac injuries. In this series, which consisted of 53 patients sustaining penetrating injuries and 9 sustaining blunt injuries, transdiaphragmatic windows were positive in 19 patients, 17 of which subsequently had documentation of cardiac injury. The authors recommended this technique as a safe and rapid method of evaluation for patients with combined thoracoabdominal injuries in proximity to the heart and believe that this technique is indicated in patients developing unexplained hypotension during abdominal exploration. Miller et al,R”in a 5-year study published in 1987 encompassing 104 patients with suspected cardiac injuries, subjected 88 of these patients to subxiphoid pericardial window, 16 via the transdiaphragmatic route in combination with

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an exploratory laparotomy. Results revealed 85 negative windows, 19 positive, 1 false positive, and 1 false negative. On the basis of this study, the authors recommended this technique as a rapid and safe means of diagnosing cardiac injuries and supported the concept that the transdiaphragmatic route is safe and can serve as an adjunct technique for patients subjected to exploratory laparotomy. Brewster et alZ3in 1988 described a series of 108 patients presenting with injuries in proximity to the heart which were evaluated with subxiphoid pericardial windows: 78 were negative (72%), 30 positive (28%), and 2 false positive (2%). This study continues to add to the literature supporting the reliability and rapidity with which windows can identify cardiac injuries. Simultaneously, the study also recommends this technique as one that can quickly identify or exclude cardiac injury. Duncan et a P in 1989 performed subxiphoid pericardial windows on patients admitted with juxtacardiac injuries. Fifty-one patients underwent this procedure for suspected cardiac injuries: 12 (23.5%) harbored hemopericardium with confirmed cardiac injuries at sternotomy. On the basis of this study, they recommended this technique as a safe, expeditious, and accurate method of identifying cardiac injuries. This procedure is still being widely employed in many urban trauma centers in the United States and in foreign countries where newer diagnostic modalities such as echocardiography are not readily available. Andrade-Alegre and Mon2 in 1994 reported their experience in Panama in a series of 76 patients, 16 (21%) of which were positive windows, with no false positives or false negatives. The advantages of this technique are safety and reliability in detecting hemopericardium. It is a relatively simple surgical technique that belongs in the surgical armamentarium of every trauma surgeon. Its disadvantages consist of having to subject the patient to a general anesthetic and a surgical procedure. The role of the subxiphoid pericardial window will diminish as diagnostic echocardiography undergoes technical refinement; however, it still remains the gold standard in the evaluation of cardiac injuries.

Two-Dimensional Echocardiography

Echocardiography is currently emerging as the newest technique for the evaluation of penetrating cardiac injuries (Figs. 8, 9, and 10). Feigenbaum and co-workers,4HsMoss and Bruhn,goand Goldberg et aP6began to define echocardiography as a valuable technique in diagnosing pericardial effusions in 1965. During the decade of the 1970s, noninvasive bedside diagnosis of pericardial effusions by echocardiography gained general acceptance. Horowitz et a P in 1974 began to define the limits of sensitivity and specificity of this technique. They concluded that a minimum of 50 mL of pericardial fluid is necessary before echocardiography can reliably demonstrate an effusion. Subsequently, Weiss et allT7and Miller et a P began to apply two-dimensional echocardiography in establishing the diagnosis of blunt cardiac injuries, namely myocardial contusions. Choo et a127in. 1984 used two-dimensional echocardiography to diagnose a pseudoaneurysm arising from the left ventricle in a patient who sustained a stab wound to the chest, with recurrence of a pericardial tamponade. In this study, the authors suggest the potential of two-dimensional echocardiography for evaluating penetrating cardiac injuries in acute situations and recommend

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Figure 8. Precordial stab wound (arrow) on a hernodynarnically stable patient.

its use in patients presenting with precordial wounds or any of the components of Beck’s triad. Lopez et al,” in a canine model, studied the echocardiographic characteristics of hemopericardium with and without thrombus formation. They concluded that hemopericardium with or without thrombus may be identified by twodimensional echocardiography and differentiated from other types of pericardial effusions of lower acoustic density. Hassett et alh’ studied nine patients with penetrating missile wounds of the heart to ascertain whether echocardiography could locate retained missile fragments that were noted by fluoroscopy to be moving in synchrony with the heart. From the data in this study, they concluded that the location of retained missile fragments can be readily defined by this technique, which could serve as a adjunct in decision making regarding the removal of these fragments. Similarly, Robinson et al,lo4using echocardiography to locate foreign bodies within the heart, concluded that missiles clearly embedded within the wall of

Figure 9. Radiographic findings for the patient in Figure 8, showing a globular heart indicating pericardial clot.

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Figure 10. Positive echocardiogram showing blood in the pericardium. Arrows show blood surrounding the heart and its interface with the epicardium.

the myocardium could be observed, whereas missiles located within any of the cardiac chambers should be removed. DePriest et a133used two-dimensional echocardiography in the ED to detect a traumatic pericardial effusion and suggested that this technique be used for the early evaluation of penetrating cardiac injuries. They considered this technique to be reliable in the detection of pericardial effusions and suggested that, if the results were positive, the surgeon would have the option of performing either a subxiphoid pericardial window or, more likely, a formal thoracotomy, depending on the hemodynamic stability of the patient. Freshman et a152used two-dimensional echocardiography emergently in the evaluation of penetrating precordial trauma. This study encompassed 36 patients sustaining precordial trauma in a period of 3 years. All patients presented with systolic blood pressures of greater than 90 mm Hg; 32 (89Y0)of the patients had normal studies, 3 had small effusions, and only 1 failed to resolve secondary to a left ventricular wound. The authors concluded that although the yield of this procedure may be low, it could become a valuable tool in assessing penetrating precordial injuries. Jimenez et a17*prospectively compared hemodynamically stable patients admitted with penetrating chest wounds located within the precordial boundaries. Seventy-three patients underwent two-dimensional echocardiography followed by subxiphoid window; there were 64 negative and 9 positive windows. Echocardiography was found to have a 96% accuracy, 97% specificity, and 90% sensitivity in detecting penetrating cardiac injury. Only one patient had a false-negative finding on echocardiography. From these findings, the authors proposed that bedside two-dimensional echocardiography become the procedure of choice for the diagnosis of occult cardiac injury in patients with stable vital signs who have sustained penetrating thoracic injuries in proximity to the cardiac silhouette. Hummer et a1,98in a retrospective series consisting of 49 penetrating cardiac injuries, stratified patients into two groups-those studied with echocardiography versus those that were not. The first group consisted of 28 patients, with a mean period of time from diagnosis to definitive surgical procedure of 15.5

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minutes and 100% predicted survival. The nonstudy group consisted of 21 patients who had a mean time of 42.4 minutes from the establishment of the diagnosis to reaching definitive surgical care and a 57% survival rate. From these data the authors concluded that two-dimensional echocardiography can decrease the time to establish the diagnosis of penetrating cardiac injury and thus increase the survival rate and improve the neurologic outcome of survivors. Aaland et all reported 53 patients with penetrating precordial injuries who were hemodynamically stable when admitted. All of these patients underwent echocardiography, resulting in 51 negative and 2 positive studies. These two patients subsequently underwent pericardial windows, both of which were negative. From these data the authors found echocardiography to be a sensitive noninvasive method in the evaluation of hemodynamically stable patients sustaining penetrating precordial wounds in proximity to the heart. Meyer et al,R3in what is perhaps the most comprehensive study, prospectively evaluated 105 hemodynamically stable patients sustaining thoracic injuries for the presence of occult cardiac injuries. All patients underwent two-dimensional echocardiography followed by subxiphoid pericardial windows. For the entire group the subxiphoid window revealed a sensitivity of 100% and specificity and accuracy of 92%, versus echocardiography, with a reported sensitivity of 56%, specificity of 93%, and accuracy of 90%. However, when the subxiphoid pericardial window was compared with echocardiography in patients without hemothorax, their sensitivity (100Y0 versus loo%), specificity (89% versus 91./0), and accuracy (90% versus 910/,) were comparable. From these data the authors concluded that echocardiography has significant limitations in identifying serious cardiac injuries in patients with hemothorax; however, in patients without hemothoraces, echocardiography missed no significant injuries and may be an acceptable diagnostic option for detecting significant cardiac injuries in patients sustaining penetrating injuries in proximity to the heart. At the Los Angeles County/University of Southern California Trauma Center, echocardiography is employed aggressively in both hemodynamically stable and unstable patients, allowing trauma surgeons to proceed directly to median sternotomy and, in a significant number of cases, eliminating the need for subxiphoid pericardial windows (Figs. 11 and 12). Conversely, patients who are hemodynamically stable when admitted, with negative echocardiograms, have been observed safely and subsequently discharged. The only exceptions were a few patients whose echocardiograms were reported as negative, but in whom clinical suspicion and change in vital signs prompted immediate surgical intervention to effect a definitive repair. Although these data have yet to be subjected to statistical analysis, we believe that echocardiography is rapidly defining its niche in the management of penetrating cardiac injuries. Its role is limited by operator skill and availability of equipment, which are viewed as its two main disadvantages. Although it has yet to replace subxiphoid pericardial window in many trauma centers, we strongly believe that it can, notwithstanding its limitations, effectively replace this technique in the future, although further studies are needed. EMERGENCYDEPARTMENTTHORACOTOMY

ED thoracotomy is a surgical procedure of great value if undertaken following strict indications for its performance. This procedure is routinely performed in urban trauma centers that receive patients “in extremis.” This technically complex and challenging procedure should be performed by surgeons who are

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Figure 11. Pneumopericardium (arrow) from a stab wound. This radiographic finding should be evaluated with echocardiography. (Courtesy of Demetrios Demetriades, MD, PhD, FACS.)

Figure 12. Hemopericardium from a stab wound. Arrow points to intrapericardial fluid level. This radiographic finding should be evaluated with echocardiography or a subxiphoid pericardial window.

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familiar with the management of penetrating cardiothoracic injuries. As the emergency medical services of many large cities continue to improve and to apply the concept of "load and go," many of these patients reach urban trauma centers in dire need of immediate control of exsanguinating hemorrhage secondary to penetrating injuries to the heart and major thoracic blood vessels. When performed in an expedient fashion, ED thoracotomy with aortic crossclamping, open cardiopulmonary massage, and immediate cardiorrhaphy is successful in salvaging 10% of all penetrating cardiac injuries. Open cardiopulmonary massage after definitive repair of penetrating cardiac injuries is more effective in producing a greater ejection fraction. If definitive repair cannot be accomplished, temporary control of the injury, along with the use of adjunct measures such as balloon tamponade, can also be effectively accomplished. Similarly, lacerations of major thoracic blood vessels can also be controlled by means of vascular clamps. Prehospital factors predictive of poor outcome include absence of vital signs, fixed and dilated pupils, absence of cardiac rhythm, and absence of motion of the extremities. Similarly, the absence of a palpable pulse and the presence of cardiopulmonary arrest are predictors of poor outcome. Generally accepted indications for this procedure include cardiopulmonary arrest secondary to penetrating thoracic injuries and profound shock with systolic blood pressures of less than 60 mm Hg due to either exsanguinating hemorrhage or pericardial tamponade. Cardiopulmonary arrest secondary to blunt injury is generally a contraindication to the performance of this procedure. The objectives to be achieved with this procedure include resuscitation of agonal patients arriving with penetrating cardiothoracic injuries, evacuation of pericardial tamponade, control of massive intrathoracic hemorrhage secondary to cardiovascular injuries, prevention of air emboli, and restoration of cardiac function using open cardiopulmonary massage. Other objectives accomplished are definitive repairs of penetrating cardiac injuries and control of exsanguinating thoracic vascular injuries. Similarly, cross-clamping of the descending thoracic aorta, redistributing the remaining blood volume to perfuse the carotids and coronary arteries, is achieved with this technique. ED thoracotomy should be performed simultaneously with the initial assessment evaluation and resuscitation, using the Advanced Trauma Life Support (ATLS) protocols of the American College of Surgeons (ACS). Similarly, immediate venous access with simultaneous use of rapid infusion techniques complements the resuscitative process. Patients are generally transferred to the ED gurney upon arrival. The left arm is elevated and the entire thorax is prepped rapidly with an antiseptic solution. A left anterolateral thoracotomy commencing at the lateral border of the left sternocostal junction and inferior to the nipple is carried out and extended laterally to the latissimus dorsi. In females, the breast is retracted cephalad. This incision is rapidly carried through skin and subcutaneous tissue and the serratus anterior until the intercostal muscles have been reached. The three layers of these interdigitated muscles are sharply transected with scissors. Occasionally, the left fourth and fifth costochondral cartilages are transected to provide a greater exposure. A Finochietto retractor is then placed to separate the ribs. At that time the surgeon should evaluate the extent of the hemorrhage present within the left thoracic cavity. An exsanguinating hemorrhage with almost complete loss of the patient's intravascular volume is a reliable indicator of poor outcome. The left lung is then elevated medially and the thoracic aorta is located immediately as it enters the abdomen via the aortic hiatus. The aorta should then be palpated to assess the status of the remaining blood volume. It can also

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Figure 13. Descending thoracic aorta as it enters the aortic hiatus. The aorta has been circumferentially dissected prior to placement of the aortic cross-clamp. Note the esophagus superiorly.

be temporarily occluded digitally against the bodies of the thoracic vertebrae. To fully cross-clamp the aorta, a combination of sharp and blunt dissection commencing at both the superior and inferior borders of the aorta is performed, so that the aorta may be encircled between the thumb and index fingers, in order for the aortic cross-clamp to be safely placed. Inexperienced surgeons often mistakenly grasp the esophagus, which is located superior to the aorta, and cross-clamp it erroneously. A nasogastric tube previously placed can serve as a guide in differentiating the esophagus from an often somewhat empty thoracic aorta (Figs. 13 and 14). Surgeons should then observe the pericardium and search for the presence of a pericardial laceration. Other observations pertain to the pericardium, which is usually tense and bluish. The phrenic nerve must also be identified and preserved. A longitudinal opening in the pericardial sac is then made anterior

Figure 14. Aortic cross-clamp in place. Note the size of the left hemithoracic cavity, which can accommodate the patient’s entire blood volume in exsanguinating injuries.

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to the phrenic nerve and extended inferiorly and superiorly. Opening the pericardium can be challenging. Often the sac is quite tense, and injudicious opening with the knife may iatrogenically lacerate the underlying epicardium. Usually it is necessary to grasp the pericardium with two Allis clamps to steady it and then to make a small, 1- or 2-cm incision sharply with the knife, followed by opening the pericardium with scissors. After opening the pericardium, the clotted blood is evacuated and the surgeon should immediately note the presence, absence, and type of underlying cardiac rhythm as well as the location of the penetrating injury or injuries. Immediate digital control is a must. An attempt must be made to elucidate the trajectory of the wounding agent, as missiles often enter in one area and migrate to adjacent areas such as the contralateral hemithoracic cavity. Similarly, the surgeon should also estimate the blood volume remaining within the cardiac chambers. The finding of a flaccid heart devoid of any effective forward pumping motion is a predictor of poor outcome. Other predictors of poor outcome are empty coronary arteries and the presence of air, which at times may be seen in the coronary veins (Fig. 15). Digital control of penetrating ventricular injuries as they are simultaneously sutured prevents further hemorrhage. We generally recommend the use of monofilament suture, such as 2-0 prolene. Lacerations of the atria can be controlled with a vascular clamp such as a Satinsky prior to definitive cardiorrhaphy. If the injury or injuries are quite large, balloon tamponade using a Foley catheter can temporarily arrest the hemorrhage either to allow the performance of cardiorrhaphy or to gain time so that the patient may be transferred expediently to an operating room for a more definitive surgical procedure. We do not recommend the use of bioprosthetic materials such as Teflon patches in the ED. This is a time-consuming technique that, if needed, should be done in the operating room. Macho recommends the use of a skin stapler to temporarily occlude lacerations in the cardiac muscle so as to allow expedient transfer to the operating room for definitive cardiorrhaphy. In this series, the authors recommend that these staples be removed and replaced with sutures. In some cases they have left them in place, allegedly with no untoward effects. No long-term follow-up is provided in this series. In our experience, the staples do not effectively control hemorrhage, tend to enlarge the cardiac injury, and prove to be rather difficult to remove (Fig. 16). Although successful repairs are denoted by cessation of bleeding and pro-

Figure 15. Air embolus (arrow) within the coronary veins.

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Figure 16. Staples in the heart (arrow). Cardiac laceration was stapled in the emergency department. The patient was transferred to the operating room for definitive cardiorrhaphy. Some staples were removed.

gressive filling of the cardiac chambers, they may be effectively accomplished without the heart being able to recover its rhythm. Strict pharmacologic manipulation coupled with directly delivered countershocks of 20 to 50 joules is frequently needed to restore a normal sinus rhythm. If sinus rhythm cannot be restored despite all attempts, the prognosis is grave and the outcome is poor. At times a rhythm can be restored, but no effective pumping mechanism is observed. Similarly, no pulsations are detected in the descending thoracic aorta. Progressive myocardial death can be witnessed, first by dilatation of the right ventricle with accompanying cessation of contractility and motion, followed by the same process in the left ventricle. TECHNIQUES OF CARDIAC INJURY REPAIR

Incisions

In contrast to abdominal injuries that can easily be accessed via a celiotomy, the management of penetrating cardiothoracic injuries requires exquisite judgment in selecting the best approach to these injuries. Exercising the wrong choice allows the surgeon no opportunity to exercise his second choice, given the critical nature and severe hemodynamic compromise of these patients. It therefore behooves the surgeon to think critically and choose wisely. The surgeon should be aware that injuries caused by missiles can be totally unpredictable in their trajectory. A missile injury that penetrates a hemithoracic cavity may not remain confined to the original area of entrance and may indeed migrate to the contralateral cavity. Familiarity with this concept may lead the surgeon to open the contralateral hemithoracic cavity in his search for other injuries when the indications exist. The five most commonly used incisions in the management of penetrating cardiothoracic injuries are (1) the median sternotomy, (2) the "book," (3) the posterolateral, (4) the left anterolateral, and (5) bilateral anterolateral thoracotomies. Each incision has its specific indications, advantages, and disadvantages.

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The median sternotomy is the incision of choice in patients admitted with penetrating precordial wounds that may harbor an occult cardiac injury. Those admitted with some degree of hemodynamic stability may undergo some preoperative investigation with chest radiography or echocardiography. Those that reach the operating room with some degree of stability can undergo a subxiphoid pericardial window. The ”book” thoracotomy has been described for the management of injuries to the thoracic inlet, particularly those at the origin of the subclavian vessels. It is the incision of choice in the management of combined cardiac and thoracic inlet vascular injuries. The classic posterolateral thoracotomy incision is not useful in the management of these injuries. This incision is better suited for the management of noncardiac thoracic injuries, such as aortic or pulmonary (left posterolateral) or pulmonary or esophageal (right posterolateral) injuries. The left anterolateral thoracotomy is the incision of choice for the management of patients with penetrating cardiac injuries who arrive “in extremis.” This incision is most often used in the ED for resuscitative purposes. Similarly, it is the incision of choice in patients undergoing celiotomy who deteriorate secondary to possible or unsuspected cardiac injuries. The left anterolateral thoracotomy can be extended across the sternum as bilateral anterolateral thoracotomies if the patient’s injuries extend into the right hemithoracic cavity (Fig. 17). This is the incision of choice in a patient who is hemodynamically unstable owing to injuries that have traversed the mediastinum or one who has sustained associated abdominal injuries. It allows full exposure of the anterior mediastinum and pericardium and both hemithoracic cavities. It is important to note that upon transection of the sternum both internal mammary arteries are sacrificed and must be ligated at the completion of the procedure. Frequently, surgeons in haste to terminate the procedure neglect to ligate these vessels, prompting the patient’s return to the operating room for recurrence of bleeding. Adjunct Maneuvers

Surgeons must possess several maneuvers in their armamentarium to deal with penetrating cardiothoracic injuries. Sauerbruch106described a maneuver for

Figure 17. Bilateral anterolateral thoracotomies along with celiotomy were needed to manage this patient, who sustained thoracoabdominal injuries and arrived “in extremis.”

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Figure 18. Clamping of the superior and inferior vena cavae (inferior vena cavae clamped at the space of Gibbon’s).This maneuver produces total inflow occlusion with subsequent cardiac emptying and arrest. Notice vascular clamp used to retract the right atrial appendage to provide greater exposure.

controlling blood flow to the heart by compression of the base. This maneuver is difficult and not easily performed via a left anterolateral thoracotomy. It is infrequently used. Total inflow occlusion of the heart is indicated for the management of injuries in the lateralmost aspect of the right atrium and/or the superior or inferior atriocaval junction (Fig. 18). These areas are quite inaccessible and tend to bleed profusely. This maneuver is performed by cross-clamping the superior and inferior venae cavae, resulting in immediate emptying of the heart. The tolerance of the injured, acidotic, and ischemic heart for this maneuver is quite limited. Frequently, this procedure results in cardiopulmonary arrest from which the patient may not be salvaged. It is estimated that the safe period for this maneuver ranges from 1 to 3 minutes, after which clamps must be released. If this period is exceeded, successful restoration of a normal sinus rhythm is not possible. Clamping the pulmonary hilum is another valuable maneuver indicated for the management of associated pulmonary injuries with rapid hemorrhage (Fig. 19). This maneuver arrests bleeding from the lung and prevents air emboli from reaching the systemic circulation. However, it does significantly increase the afterload of the right ventricle, as half of the pulmonary circulation is no longer available for perfusion. It is recommended that sequential declamping of the pulmonary hilum be carried out as expediently as possible simultaneously with clamping the intraparenchymal pulmonary vessels responsible for the hemorrhage. This unloads the right ventricle. Frequently an acidotic and ischemic heart may not be able to tolerate this maneuver and fibrillates or arrests. Recently, Grabowski et a15’ described a maneuver to facilitate exposure of posterior cardiac wounds. This maneuver entails placing a Satinsky clamp at the right ventricular angle, which is formed by the acute anteroinferior margin of the right ventricle where it reflects on the right diaphragm. The clamp should grasp only a small portion of the right ventricle. It is used to elevate the heart out of the pericardium to repair posterior injuries. The authors have no experience with this maneuver but strongly suspect that its use by inexperienced surgeons may lead to cardiac dysrhythmias or arrest.

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Figure 19. Vascular clamps applied to pulmonary hilum. This maneuver is sometimes needed to manage associated penetrating wounds to the lung presenting with massive

bleeding. Repair of Atrial Wounds

Atrial injuries can be controlled by a Satinsky clamp. Occlusion of the wound by this clamp allows the surgeon to perform a repair using a 2-0 prolene monofilament suture in a running or interrupted fashion. The thin walls of the atria demand gentleness during suturing, as they can easily tear and enlarge the original wound. The use of bioprosthetic material in the form of Teflon patches is not recommended for management of these injuries. Repair of Ventricular Wounds

Ventricular wounds may be repaired by digitally occluding the laceration while placing either simple interrupted or horizontal mattress sutures of Halsted. Similarly, they can also be repaired with a running monofilament suture of 2-0 prolene. Repairing cardiac lacerations from stab wounds is less challenging than repairing gunshot wounds. Gunshot wounds tend to produce some degree of blast effect that causes difficulties in their repair. Frequently, perforations caused by gunshots that have been initially sutured and controlled enlarge as the damaged myocardium becomes more friable. Frequently, these injuries require multiple sutures in a desperate attempt to control torrential bleeding. When this scenario occurs, bioprosthetic materials such as Teflon are needed to buttress the suture line (Fig. 20). Management of Coronary Artery Injuries

The repair of ventricular wounds adjacent to coronary arteries can be quite challenging. Injudicious placement of sutures may narrow or occlude a coronary artery or one of its branches. Consequently, it is recommended that sutures be placed underneath the bed of the coronary artery. Lacerations in proximal locations of the coronary arteries may demand the use of cardiopulmonary bypass for repair, although this is infrequently necessary. Lacerations of distal coronary arteries, particularly the distal third of the vessel, should be managed

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Figure 20. Left ventricular gunshot wound repaired with Teflon patch.

by ligation (Fig. 21). In desperation, proximal coronary artery wounds are often ligated, resulting in immediate myocardial infarctions at the operating table. These patients might benefit from the institution of intra-aortic balloon counterpulsation71or aortocoronary bypass. The Use of Bioprosthetic and Autogenous Materials

Although many surgeons have been schooled in the use of Teflon pledgets or strips to buttress suture lines on friable myocardial tissue, no evidence exists in the literature that supports their use for enhancement of cardiac wound healing. No evidence is available that Teflon increases tensile strength of the myocardium. Mattox et alS1provide the first reference in the literature alluding to the use of this material. The use of autogenous material such as pericardium to bolster suture lines is well known. A small flap is developed and excised from the pericardium to be used in a manner similar to the use of Teflon pledgets.

Figure 21. Left ventricular cardiorrhaphy with ligation of distal third left anterior descending coronary artery. Arrow points to ligated vessel. Forceps point to the left anterior descending coronary artery. Note area of previous infarction.

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Table 1 . AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) ORGAN INJURY SCALING (01s): HEART INJURY SCALE

Grade*

Injury Description

I

Blunt cardiac injury with minor electrocardiographic abnormality (nonspecific ST- or T-wave changes, premature atrial or ventricular contraction, or persistent sinus tachycardia) Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade, or cardiac herniation

II

Blunt cardiac injury with heart block (right or left bundle branch, left anterior fascicular, or atrioventricular) or ischemic changes (ST depression or T-wave inversion) without cardiac failure Penetrating tangential myocardial wound up to, but not extending through, endocardium, without tamponade

111

Blunt cardiac injury with sustained (23 beatshin) or multifocal ventricular contractions Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid valvular incompetence, papillary muscle dysfunction, or distal coronary arterial occlusion without cardiac failure Blunt pericardial laceration with cardiac herniation Blunt cardiac injury with cardiac failure Penetrating tangential myocardial wound up to, but not extending through, endocardium, with tamponade

IV

Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid valvular incompetence, papillary muscle dysfunction, or distal coronary arterial occlusion producing cardiac failure Blunt or penetrating cardiac injury with aortic or mitral valve incompetence Blunt or penetrating cardiac injury of the right ventricle, right atrium, or left atrium

V

Blunt or penetrating cardiac injury with proximal coronary arterial occlusion Blunt or penetrating left ventricular perforation Stellate wound with 4 0 % tissue loss of the right ventricle, right atrium, or left atrium

VI

Blunt avulsion of the heart; penetrating wound producing >50% tissue loss of a chamber

'Advance one grade for multiple penetrating wounds to a single chamber or multiple chamber involvement. From Moore EE, Malangoni MA, Cogbill TH, et al: Organ injury scaling IV: Thoracic, vascular, lung, cardiac, and diaphragm. J Trauma 36:229-300,1994; with permission.

INJURY SCALING

The American Association for the Surgery of Trauma (AAST) and its Organ Injury Scaling (01s) Committee have developed a cardiac injury scale to uniformly describe cardiac injuries87(Table 1). This scale is quite complex, and although it comprehensively describes these injuries, it does not provide any prediction of outcome. No figures exist yet in the literature describing the mortality for each grade of injury. COMPLEX AND COMBINED INJURIES

Surgeons in trauma centers are developing greater expertise in the management of penetrating injuries. As patients are subjected to greater degrees of

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Figure 22. Right hemithoracic gunshot wound on a patient who arrived in shock. The

patient underwent bilateral anterolateral thoracotomies and celiotomy. violence in the arenas of urban warfare, many patients arrive harboring multiple associated injuries in addition to their penetrating cardiac injuries (Figs. 22 to 25). Complex and combined cardiac injuries can be defined as a cardiac injury plus associated neck, thoracic, thoracic-vascular, abdominal, or abdominal-vascular injuries. In addition, any extremity or peripheral vascular injury can be considered as one of these types of injuries (Figs. 26 to 28). These injuries are quite challenging to manage. Priority should be given to the injury causing the greatest blood loss.

Figure 23. Orifices of entrance and exit in the pericardium. Missile entered at the inferior atriocaval junction and exited at the lateral-most aspect of the right atria. Note the two suture lines in the same patient.

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Figure 24. Arrows point to the repaired inferior atriocaval junction and lateral aspect of right atria. This patient needed total inflow occlusions with cross-clamping of both the superior and inferior venae cavae in the intrapericardial part of these vessels.

Figure 25. Missile also lacerated the right upper lobe and was located adjacent to the right subclavian vessels. Note the large caliber of the missile. This patient also sustained injuries to the right colon, small bowel, duodenum, liver, and diaphragm and survived.

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Figure 26. Complex and combined injuty in a 16-year-old male patient sustaining 13 gunshot wounds. He had an emergency department thoracotomy with left ventricular cardiorrhaphy and was eventually transferred to the operating room. The entrance wound in the anterior wall of the left ventricle was repaired with Teflon.

Figure 27. Posterior left ventricular wound (arrow) in the patient in Figure 26, primarily repaired.

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Figure 28. Femorofemoral bypass with polytetrafluoroethylene conduit. The femoral vein was ligated in this patient, who is also shown in Figures 26 and 27. The patient experienced three episodes of cardiopulmonaty arrest and survived. In addition, he sustained injuries to the left lung, left femur, and right wrist.

OVERVIEW OF CURRENT PHILOSOPHIES INFLUENCING MANAGEMENT OF CARDIAC INJURIES

The difficulty in evaluating different series on penetrating cardiac injuries, along with analyzing their results, has been pointed out by T~-inkle."~ Over the past 30 years, the literature overflows with reports dealing with these injuries, the majority of which have been retrospective reviews. Most have come from institutions treating fewer than 15 such cases annually. Many reports encompass serial and overlapping studies from the same institutions. Similarly, many of the series fail to uniformly report important data that would lead to meaningful and conclusive analysis of their results. Frequently, important data points are omitted. Few series report the prehospita1 data or transport times for these patients. Similarly, data regarding indications for performing ED thoracotomy, physiologic state of the patient during transport and upon arrival, and precise reporting of the anatomic areas of injuries are often missing. Few if any series report the management of these injuries under the guidance of strict protocols. A paucity of uniform reporting of outcomes is quite noticeable. Wide variations in mortality are usually reported and appear to reflect different degrees of selection of patients for attempted resuscitation. Even less frequently reported are the results of failed resuscitative efforts. The literature abounds with studies that report high survival rates but omit the physiologic status on presentation; they are perhaps biased toward the reporting of patients with lesser degrees of anatomic and physiologic injury severity. These factors have contributed to the false perception that the lethality of cardiac injuries has diminished. This complacent attitude places limits on the development of serious scientific inquiry into this area. Fatalistic views suggesting that surgeons abandon ED thoracotomy as an ineffective, expensive, and risky procedure may also contribute to this attitude. The specter of transmissible

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diseases, such as HIV, even in the absence of proof that this disease can be transmitted through solid needle punctures has raised fears and "ghosts" in the minds of many surgeons, dampening their enthusiasm for scientific inquiry. Given the previously mentioned factors, the authors do not attempt to provide an analysis of morbidity and mortality of penetrating cardiac injuries. Instead, we have reviewed currents of thought present in the literature which have influenced and set the trends in the management of these injuries. Beall et a19 in 1961 first proposed that patients experiencing cessation of cardiac action undergo immediate thoracotomy and open cardiac massage, whether in the emergency, operating, or recovery room or on the ward. This study was the first to advocate emergency thoracotomy and recommended keeping a set of instruments in the ED ready at all times. Beall et ale also reported the benefits of cardiopulmonary bypass in the management of selected intracardiac injuries, such as aortoatrial and aortoventricular fistulas and traumatic atrial and ventricular septa1 effects. Beall et a16also described the management of cardiac lacerations adjacent to coronary arteries as well as the techniques to repair these injuries while preserving the integrity of the vessels. Boyd and StriedeP statistically analyzed 25 patients with penetrating cardiac injuries. Three patients underwent ED thoracotomies with no survival. The remaining 22 patients were stratified into two groups. The first group experienced delays in reaching the operating room of greater than 2 hours, and all 4 succumbed. The second group reached the operating room in less than 2 hours. In this group 17 of 18 patients survived. This difference was statistically significant. The authors concluded that rapid transport to surgical intervention is mandatory and increases survival. This paper focused the attention of surgeons on time as a critical factor affecting survival. Sugg et a P 2 analyzed a series of 459 penetrating wounds of the heart. In this group 373 were dead on arrival. This study pointed to the very high prehospital mortality experienced with gunshot wounds owing to their greater severity. On the basis of these data, Sugg et a1 recommended immediate surgical intervention, which would lead to greater survival rates. Beall et a17 in 1971 supported a change in the pattern of surgical management of penetrating cardiac injuries while strongly advocating the use of thoracotomy and cardiorrhaphy without pericardiocentesis. Steichen et all" recommended the performance of ED thoracotomy and cardiorrhaphy in "lifeless" patients. This study recommended an aggressive approach to the management of these injuries and detailed the pharmacologic management of cardiac dysrhythmias encountered during this procedure. This paper launched emergency department thoracotomy as an acceptable procedure in the management of penetrating cardiac injuries. Mattox et a180 reported on 147 patients with penetrating cardiac injury undergoing ED thoracotomy with a 67.5% salvage rate. In this paper, Mattox and associates strongly advocated ED thoracotomy as the primary modality in the management of moribund patients with penetrating wounds of the chest. Espada et a14' reported on the management of penetrating coronary artery injuries. They advocated ligation as the treatment of choice for most coronary artery injuries and also recommended the use of cardiopulmonary bypass in selected cases in which ligation of a proximal coronary artery had led to the development of myocardial infarction. Ivatury et a170 advocated the use of ED thoracotomy for the resuscitation of patients with "fatal" penetrating injuries of the heart. In their study of 75 patients, 22 (29.3%)arrived with absent vital signs. Sixteen of these 22 patients (72.7%)had successful restoration of cardiac activity after ED thoracotomy was

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performed, and 8 (36.4%) survived. This study focused attention on the increased survival rates with aggressive application of this technique. Gervin and F i s ~ h e r ~ ~ reported on 23 patients, 13 of whom were potentially salvageable. These patients were stratified into two groups; the first group was immediately transported and arrived within 9 minutes at the trauma center. Five of these six patients survived. The second group of patients underwent field stabilization lasting greater than 25 minutes, and all seven patients died. On the basis of these data, the authors suggested that prompt transport to trauma centers without attempts at field resuscitation increases survival in patients with penetrating heart injury. Bodai et all8 outlined the indications for the performance of ED thoracotomy for both penetrating and blunt trauma and recommended against performing this procedure in patients sustaining cardiopulmonary arrest from blunt injury. Rohman et allo5classified patients into four groups based on the severity of their injury. Group I (fatal) and group I1 (agonal) had survival rates of 32% and 33%, respectively. Group I11 (profound shock) had a survival rate of 40%. Group IV (dead on arrival) had no survivors. On the basis of these data, the authors concluded that ED thoracotomy is essential for patients with fatal and agonal wounds and advised prompt intervention in patients admitted in profound shock. This paper, for the first time, attempted to add selectivity in the performance of this procedure. Mattox et a1,82 in an important paper, recommended the use of postoperative two-dimensional echocardiography to assess patients surviving penetrating cardiac injuries and reported on a group of patients who had intracardiac injuries demanding reoperation. Without echocardiography, these patients otherwise would not have been detected. Given their findings, they recommended screening all survivors postoperatively to detect these injuries. Ivatury et aP9 attempted to quantify both the anatomic and physiologic status of penetrating cardiac injury patients using the trauma score, the physiologic index, and the penetrating thoracic trauma index to compare the results of field stabilization versus immediate transportation to the trauma center. They concluded that immediate transportation without any stabilization constitutes the optimal prehospital management for these patients. Demetriades et a132 detailed the late sequelae of penetrating cardiac injuries and recommended early postoperative evaluation of these patients with electrocardiography, echocardiography, and cardiac catheterization when indicated, in combination with longterm follow-up. Esposito et al" proposed that ED thoracotomy is justified only when vital signs or a resuscitatable cardiac rhythm is present in the field or in the ED and undergoes deterioration. In this study they attempted to limit the use of this procedure by raising the specter of HIV as a potentially transmissible agent and almost succeeded in condemning the procedure completely. This study has been quoted to support abandonment of ED thoracotomy. This therapeutic nihilism is unwarranted if one realizes that of the 112 patients reported in a 4-year period, 88 (79%) sustained blunt cardiac injury. The almost imperceptible salvage rate of these patients accounts for the low survival rate in this series. Incredibly enough, the authors continued to perform this procedure despite the currently accepted contraindication to ED thoracotomy in blunt cardiopulmonary arrest. In this series, there were 24 penetrating injuries in a period of 4 years, averaging eight cases per year. This low volume of penetrating cardiac injuries precludes meaningful development of any expertise in the management of these injuries. Lorenz et a178associated survival with the physiologic status of patients in the field and upon arrival in the ED, using systolic blood pressure of less than 60 mm Hg as a predictive factor. Durham et a136 concluded that a limited

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period of prehospital cardiopulmonary resuscitation (less than 5 minutes) is a significant predictor of outcome in surviving patients and links prehospital endotracheal intubation with tolerance and prolongation of successful cardiopulmonary resuscitation. Millham and GrindlingeF correlated the presence of vital signs in the field or upon arrival in the ED and recommended that patients with penetrating chest wounds without vital signs in the field or upon hospital arrival be excluded from ED thoracotomy. The authors base this conclusion on an analysis of 3845 ED thoracotomies, 2253 of which were performed for penetrating chest injuries. In this series 350 (16%) survived. Buckman et al," using the cardiovascular and respiratory elements of the trauma score (CVRS) on admission, prospectively analyzed 66 consecutive cardiac injuries in a 2-year period. In this group of patients, 44 (70%) sustained gunshot wounds, 47 (71%) were subjected to ED thoracotomy, and 54% were admitted in asystole. On the basis of their data, the authors concluded that prospective physiologic scoring was helpful in predicting outcomes. The triad of gunshot wounds, asystole, and CVRS=O was proven to predict survival, whereas the triad of stab wounds, asystole, and CVRS = 0 could not predict survival. Coimbra et a1,28using several different trauma indices, concluded that they are valid as predictors of outcome and proposed the use of standard terminology in describing penetrating cardiac injuries. It is apparent from this review of the literature that much remains to be done in terms of anatomic and physiologic injury assessment. Similarly, a better selection of patients through use of physiologic indices such as the CVRS to undergo ED thoracotomy and cardiorrhaphy might lead to improved survival. Only with serious scientific inquiry based on prospective collection and analysis of data can we extend the frontiers in the management of these devastating injuries, much like Cappelen," and Rehn'O' did 100 years ago.

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