Penetrating Wounds of the Heart

Penetrating Wounds of the Heart· H. Sustaita, M.D.,oO R. K. Balsara, M.D.,oO F. N. Niguidula, M.D." and ]. C. Davila, M.D.$

Two cases of injury to tbe interatrial septnm are presented. In one, tamponade elfeet and permanent damage of the conduction system occurred after an ice pick wound. Electrocardiographic findings of A-V dissociation are sbown. In the second case, a buDet injury to tbe interatrial septum with lodgement of tbe missile and acute tamponade, no injury to tbe conduction system bas been evidenced. The reasons for surgical exploration in eacb instance are given.

cases of penetrating trauma to the T wochestunusual with injury to the atrial septum are re-

(upper sternum) at the level of the second intercostal space. Transient dizziness and later an oppressive sensation in the chest followed the incident. The family history was irrelevant. Pulse rates recorded during two previous hospitalizations in two local hospitals in 1964 and 1965 for abdominal stab wounds and in the outpatient department at Temple in 1967 were as follows: 80 to 100 beats/min (blood pressure 110/70 mm Hg), 94/min (blood pressure 160/90) and lOO/min (blood pressure 140/70). No electrocardiograms had ever been taken. Physical examination revealed a well-developed, obese, anxious man, resting in a semisitting position and complaining of slight discomfort in his chest, but able to move about. The pulse rate was 80/min (blood pressure 170/100 mm Hg); respirations were 24/min. Central venous pressure measured in the left subclavian vein was 33 em H 20. The neck veins were not distended. On auscultation of the chest, the heart sounds were distant, and respirations were shallow. There were no other signi6cant 6ndings. Results of laboratory studies were: hemoglobin content

ported. Persistent heart block developed in one patient, stabbed with an ice pick, in whom conduction damage was not expected. No evidence of conduction damage appeared in the second patient, who suffered a gunshot wound with lodgement of the bullet in the atrial septum. Harken reported the first large series of cases in which consistent success was attained in elective removal of foreign bodies from the great vessels, myocardial wall and cardiac chambers. Among the 134 cases reported in 1946,1-3 he did not encounter the lesions described in our two cases. Further review of the literature failed to reveal any similar injuries. 4 -30 Most instances of traumatic heart block result from embarrassment of the blood supply to the conduction system or from surgery of congenital or acquired heart conditions. Although direct trauma to the chest, penetrating or blunt, can cause disruption of the conduction system, the magnitude of the injuries seldom permits long enough survival for permanent conduction damage to be observed. CASE REPORTS

1 A 49-year-old Negro man was brought to the Accident Dispensary of Temple University Hospital on May 10, 1968, after he had been stabbed with an ice pick in the midline

CASE

·From the Section of Thoracic and Cardiac Surgery, Department of Surgery, Temple University Health Sciences Center, Philadelphia, Pennsylvania. ··Resident Physician, Thoracic and Cardiac Surgery, Temple University Health Sciences Center. fAssistant Professor of Surgery, Temple University Health Sciences Center. tProfessor of Surgery, Temple University Health Sciences Center.

FIGURE 1. Chest x-ray film of May 10, 1968. Posteroanterior view shows widening of the mediastinum and enlargement of the cardiac silhouette.

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PENETRATING WOUNDS OF THE HEART

FICURE 2. Lateral film in same examination as Figure 1 shows air in the retrosternal space. 12.1 gm/l00 ml, hematocrit 40 percent, and white blood cell count 1l,700/mm.a Chest x-ray films showed widening of the upper mediastinum and a somewhat enlarged, round cardiac silhouette (Fig 1). In the lateral view, air could be noted in the retrosternal space (Fig 2). The lungs were clear. The electrocardiogram showed atrioventricular dissociation with a 2:1 heart block (atrial rate 120/min, ventricular rate 6O/min) (Fig 3a). Despite lack of echocardiographic evidence of pericardial effUSion, the diagnosis of cardiac or intrapericardial great vessel injury with hemopericardium was entertained. Transdiaphragmatic pericardiocentesis yielded only 20 ml of dark blood that clotted in two minutes. After pericardiocentesis, the blood pressure suddenly dropped to 100/70 mm Hg. The pulse rate was 60 to 70 beats/min. The patient's general condition deteriorated rapidly. His skin became cold and pale. A diagnosis of pericardial tamponade was made, and the patient was operated on the evening of admission to the hospital. A midline sternotomy incision was used. The pericardium was opened, and 300 ml of liquid blood were removed. The heart was enlarged. A hematoma, 3 cm x 2 cm x 2 cm, was seen in the anteromedial aspect of the right atrial wall and extended toward the atrial septum, as determined by palpation through the invaginated atrial appendage. There was no active bleeding anywhere. Blood pressure during the surgical procedure was 100/70 mm Hg, and the electrocardiogram showed atrioventricular dissociation with a ventricular rate of 60 to 70 beats/min. Because the electrocardiogram was stable, it was elected not to implant pacemaker electrodes; it would be simple to place a temporary transvenous electrode later if this was needed. When the pericardium was closed, the blood pressure decreased to 80/60 mm Hg. The pericardium was therefore left wide open. The immediate postoperative course was complicated with bilateral lower-lobe atelectasis which cleared readily. Transient bilateral ankle edema was also observed. Renal function was normal. Auscultation of the heart revealed a systolic murmur over the precordium, well heard at the apex and

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radiating to the left axilla. Complete heart block persisted with an atrial rate of 120 beats/min and a ventricular rate of 60 beats/min (Fig 3c). The patient was discharged and followed in Cardiac Clinic. He was readmitted to the hospital two months later because of precordial pain and shortness of breath on exertion. His blood pressure was 160/70 mm Hg, heart rate 60 beats/min. The systolic murmur was unchanged, and the heart block persisted (Fig 3d). At cardiac catheterization, hemodynamic changes consistent with pericardial restriction and mitral insufficiency were observed. At the present time, the patient is in good health; he tolerates mild exercise but becomes dyspneic on moderate exercise. Implantation of a permanent pacemaker is being considered. CASE 2 A 16-year-old Negro man was admitted to Temple University Hospital on July 13, 1968, one-half hour after being shot in the right upper area of the back with a 0.32 caliber pistol. He was of average physical stature. He was in acute distress from a bleeding wound about 5 cm lateral to the midline at the level of the inferior angle of the scapula. There was no exit wound. The blood pressure was 150/80 mm Hg, and the heart rate was regular at 130 beats/min. The neck veins were mildly prominent in the supine position. No murmurs were heard over the precordium. Bilateral rales, chieHy expiratory, were present in both lung bases. There was no evidence of pneumothorax. The electrocardiogram showed sinus tachycardia (130 beats/min). While

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FICURE 3. Electrocardiogram, lead II: (a) May 10, 1968 (on admission), (b) May 21, (c) June 18, (d) July 22, 1968.

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SUSTAITA ET AL of injury to the great vessels. During total cardiopulmonary bypass, the bullet was removed from the interatrial septum through a right atriotomy, and the partial septal defect was sutured. There was no evidence of atrioventricular block. The postoperative course was uncomplicated. No further gastrointestinal bleeding occurred, and traumatic perforation of the esophagus was ruled out by a barium swallow study. The patient was discharged from the hospital two weeks later. After one month, chest x-ray examination, electrocardiogram and blood analyses were nonna!. DISCUSSION

FIGURE 4. Posteroanterior view of chest x-ray film which shows the bullet lodged in the interatrial septum. in the Accident Dispensary, the patient vomited about 100 ml of bright red blood. His past medical history was unremarkable. Laboratory studies gave the following results: hemoglobin content 11.1 gm/l00 mI, hematocrit 34 percent. The blood urea nitrogen and electrolyte values were within nonnal limits. Central venous pressure measured through the subclavian vein was 16 cm H 20. The chest x-ray film showed a 0.32 caliber bullet lodged in the heart (Fig 4, 5); this was judged by fluoroscopy to be in the interatrial septum. Thoracotomy was perfonned through a midline sternotomy incision, and 150 mI of dark blood were removed from the pericardial cavity. The bullet was palpated in the region of the interatrial septum. There was no evidence

Most heart wounds caused by medium to small caliber bullets of either low or high velocity do not impair myocardial function, providing the conduction system is not in the pathway of the projectile. Massive bleeding or pericardial tamponade is often the indication for immediate surgery. Foreign bodies in the cardiac muscle, such as shell fragments or bullets, lodge in the myocardium and cause little or no alteration in cardiac function. The main reason for their extraction is to prevent or to treat complications, such as perforation and fistulization into a neighboring vessel, the trachea, esophagus or lung. Migration of the bullet and embolization have also been reasons for extraction. Occasionally, surgery has been done to treat the anxiety attendant on a "missile in the heart," sometimes years after the insult with no proven cardiac malfunction. 2 . 19 In the second case presented here, surgery was performed to alleviate the acute pericardial tamponade and to remove the bullet from the septum, a potential hazard to the conduction system. Despite the severe contusion of the septum, no aberration in conduction occurred. In contrast, an ice pick wound usually produces little tissue destruction and seldom requires surgical treatment. One would not expect permanent conduction system damage from such a wound. In the case presented, surgery was done to relieve the acute tamponade after failure of pericardiocentesis to decompress the pericardial cavity.30 The cause of the heart block was ascertained at surgery, although no definitive treatment was instituted at that time. REFERENCES

FIGURE 5. Left anterior oblique view of chest x-ray film with the patient in the supine position shows the location of the bullet.

1 HARKEN, D.E.: Foreign bodies in, and in relation to, the thoracic blood vessels and heart, I, Surg. Gynec. Obstet., 83:117,1946. 2 HARKEN, D.E., AND ZOLL, P.M.: Foreign bodies in and in relation to the thoracic blood vessels and heart, II, Amer. Heart ].,32:1, 1946. 3 HARKEN, D.E., AND WILLIAMS, C.A.: Foreign bodies in and in relation to the thoracic blood vessels and heart, III, Amer. ]. Surg., 32:1, 1946. 4 BEALL, A.C., JR., BRICKER, 0.1., CRAWFORD, W.H., AND DEBAKEY, M.E.: Surgical management of penetrating

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PENETRATING WOUNDS OF THE HEART thoracic trauma, Dis. Chest, 49:568, 1966.

5 CosTEAS, F., FRAGOYANNIS, G., AND PONIRIDES, G.: 6 7

8

9 10 11 12 13 14 15 16

17 18

Unusual intraventricular block and acute hemopericardium, Dis. Chest, 50:423, 1966. KISHON, Y., PAUZNER, Y., DALITH, F., AND NEUFELD, H.N.: Foreign body in the myocardium as a cause of constrictive pericarditis, Thorax, 22:238, 1967. STOREY, C.F., AND KUZ~IAN, J.: Traumatic coronary artery-right atrial fistula. Successful repair of lesion caused by bullet wound of the heart, Ann. Thorac. Surg., 4:352, 1967. DOLARA, A., MORANDO, P., AND PA~IPALONI, M.: Electrocardiographic findings in 98 consecutive non-penetrating chest injuries, Dis. Chest, 52:50, 1967. LUCIDO, J.L., AND VORHEES, R.J.: Immediate thoracotomy for wounds of the heart, Amer. I. Surg., 108:664, 1964. LOGAN, W.D., JR., JORDAN, w.e., AND SORACCO, G.: Penetrating cardiac injuries, Amer. Surg., 30:664, 1964. McKAIN, ].M., WARNER, G.W., AND SHAUB, R.O.: A rocket injury of the heart-ease report, Amer. Surg., 33:742, 1967. WAITT, P.M., KINGSLEY, L., AND STEINMETZ, E.F.: Foreign bodies in the heart, Ann. Surg., 162:43, 1965. HARDY, J.D., AND WILLIA~fS, R.D.: Penetrating heart wounds: analysis of 12 consecutive cases individualized without mortality, Ann. Surg., 166:228,1967. PAULIN, C., AND RUBIN, I.L.: Complete heart block with perforated interventricular septum follOwing contusion of the chest, Amer. Heart I., 52:940, 1956. WILSON, R.F., AND BASSETT, J.S.: Penetrating wounds of the pericardium or its contents, lAMA, 195:513, 1961. BEALL, A.C., JR., DIETHRICH, E.B., CRAWFORD, W.R., COOLEY, D.A., AND DEBAKEY, M.E.: Surgical nlanagement of penetrating cardiac injuries, Amer. I. Surg., 112:686, 1966. BREWER, L.A., III, AND CARTER, R.: Elective cardiac arrest for the managelnent of massively bleeding heart wounds, ]AAIA, 200:1023, 1965. GAHAN, R., AND GREEN, E.W.: Repair of complicated

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lAMA, 194:301, 1965. 19 BLAND, E.F., AND GILBERT, W.: Missiles in the heart, New Eng. I. Med., 274:1039, 1966. 20 DOLARA, A., AND POZZI, L.: Atrioventricular and intra21 22 23 24 25

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ventricular conduction defects after nonpenetrating trauma, Amer. Heart I., 72:138, 1966. DECKER, R.H., in discussion of Biggers, I.A.: Heart wounds, I. Thorac. Surg., 8:239, 1939. RICKS, R.D., HOWELL, J.F., DEBAKEY, M.E., AND BEALL, A.C., JR.: Gunshot wounds of the heart, a review of 31 cases, Surgery, 57:787, 1965. AUBRE, L.M. DE, BROOKS, H.A., AND FROIX, C.J.L.: Penetrating wounds of the heart, Arch. Surg., 90:680, 1965. NACLERIO, E.A.: Penetrating wounds of the heart, Dis. Chest, 46:1,1964. SAUER, P.E., AND MURDOCK, C.E., JR.: Immediate surgery for cardiac and great vessel wounds, Arch. Surg., 95:7, 1967. LUI, A.H.F., GLAS, W.W., AND BERcu, B.A.: Stab wound of the heart with tamponade and interventricular septal defect, ]. Thorac. Cardiovasc. Surg., 49:868, 1965. BoYD, T.F., AND STRIEDER, J.W.: Immediate surgery for traumatic heart disease, ]. Thorac. Cardiovasc. Surg., 50:305, 1965. CHENG-CHENG, H., IbPSTEIN, C.B., AND BURNS, H.: Successful surgical management of through-and-through gunshot wound of the heart, ]. Thorac. Cardiovasc. Surg., 49:517, 1965. CLEVELAND, R.J., BENFIELD, J.R., NEMHAUSER, G.M., AND LOWER, R.R.: Management of penetrating wounds of the heart, Arch. Surg., 97:517, 1968. SUGG, W.L., REA, W.J., ECKER, R.R., WEBB, W.R., ROSE, E.F., AND SHAW, R.R.: Penetrating wounds of the heart, ]. Thorac. Cardiovasc. Surg., 56:531, 1968.

Reprint requests: Dr. Sustaita, St. Joseph's Hospital, San Francisco 94117

PUZZLING INSTANCE OF ASPIRATION PNEUMONIA Since the age of five and a haH months, a one year old infant had had "spells" of unconsciousness during meals. Clinical evidence of pneumonia shortly followed one of these incidents, and the child developed fever. Tuberculin, coccidioidin and histoplasmin tests were negative, as were nose, throat and blood cultures. Chest films showed pulmonary infiltrates. The child died in respiratory failure. At autopsy the lung;s showed patchy bronchopneumonia, with large foci of emphysema and minute abscesses. Microscopically, there were foci of typical bronchopneumonia. In addition, there were more

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or less circumscribed accumulations of polymorphonuclear leukocytes, with necrosis, small and large giant cells, and foci consisting of macrophages with necrosis. A number of microscopic fields resembled closely those seen in so-called giant cell pneumonia. Only after the examination of a number of sections could minute parts of vegetable fibers be recognized in a few bronchioles and alveoli. Saphir, 0.: A Text of System Pathology, Grone & Stratton, New York, 1958