Video-Assisted Thoracoscopy For Penetrating Cardiac Box Injury in Stable Patients

Abstract Introduction: In high-volume trauma centers, especially in developing countries, penetrating cardiac box injuries are frequent. Although many aspects of penetrating chest injuries have been well established, video-assisted thoracoscopy is still finding its place in cardiac box trauma and algorithmic approaches are still lacking. The purpose of this manuscript is to provide a streamlined recommendation for penetrating cardiac box injury in stable patients. Methods: Literature review was carried out using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics and concepts of penetrating cardiac box trauma, including the characteristics of tamponade, cardiac ultrasound, indications and techniques of pericardial windows and, especially, the role of video-assisted thoracoscopy in stable patients. Results: Penetrating cardiac box injuries, whether by stab or gunshot wounds, require rapid surgical consultation. Unstable patients require immediate open surgery, however, determining which stable patients should be taken to thoracoscopic surgery is still controversial. Here, the classification of penetrating cardiac box injury used in Colombia is detailed, as well as the algorithmic approach to these types of trauma. Conclusion: Although open surgery is mandatory in unstable patients with penetrating cardiac box injuries, a more conservative and minimally invasive approach may be undertaken in stable patients. As rapid decision-making is critical in the trauma bay, surgeons working in high-volume trauma centers should expose themselves to thoracoscopy and always consider this possibility in the setting of penetrating cardiac box injuries in stable patients, always in the context of an experienced trauma team.

O uso da tomografia computadorizada na triagem da lesão cardíaca penetrante / The use of computed tomography for penetrating heart injury screening

RESUMO Objetivo: determinar se a tomografia computadorizada representa uma opção segura para triagem de lesões cardíacas penetrantes. Métodos: estudo transversal retrospectivo, que confrontou os achados tomográficos com os detectados na exploração cirúrgica em pacientes operados por suspeita de trauma cardíaco no período de janeiro de 2016 a janeiro de 2018. Resultados: setenta e dois casos foram analisados; 97,2% eram do sexo masculino e a faixa etária mais prevalente foi de 20 a 29 anos; 56,9% apresentaram ferimentos por projéteis de arma de fogo e 43,1% por arma branca. Em 20 casos, a tomografia computadorizada foi sugestiva de lesão cardíaca, confirmada em 13 casos durante a cirurgia. A sensibilidade da tomografia computadorizada foi de 56,5% e a especificidade de 85,7%. Conclusão: a tomografia computadorizada não deve ser adotada rotineiramente para triagem de ferimentos cardíacos penetrantes.

ABSTRACT Objective: to determine if computed tomography represents a safe option for penetrating heart injury screening. Methods: retrospective transversal study which confronted tomographic findings with the ones detected in surgical exploration in patients that had undergone surgery because of suspected cardiac trauma from January, 2016 to January, 2018. Results: seventy-two cases were analysed; 97.2% of them were males, and the most prevalent age range was 20 to 29 years; 56.9% of them presented injuries caused by firearm shots and 43.1% by cutting weapons. In 20 cases, computed tomography suggested heart injury, confirmed in 13 cases during surgery. Sensitivity of computed tomography was 56.5%, reaching a specificity of 85.7%. Conclusion: computed tomography must not be adopted as a routine for the screening of penetrating heart injuries.

Heart injury with projectile lodged inside the heart

Abstract Penetrating heart injuries present high mortality rates. Increasing rates of urban violence have contributed to a significant rise in the number of heart injuries by firearm projectiles. Such injuries are associated with the highest mortality rates among penetrating cardiac injuries and may involve one or more cardiac chambers. We present the case of a police officer who, in an approach to five robbers, suffered a transfixed cardiac injury by firearm with the projectile having been lodged inside the right ventricle. This patient was successfully operated, 65 days after the injury, at our institution.

Embolization by Bullet Dislodged from the Heart

Abstract Embolization by a dislodged projectile is a rare complication that may occur in cases of gunshot cardiac injuries. We report a case of a firearm projectile cardiac injury that evolved, with dislocation of the projectile during cardiac surgery, into embolization of the right external carotid artery.

Detection of Myocardial Metabolic Abnormalities by 18F-FDG PET/CT and Corresponding Pathological Changes in Beagles with Local Heart Irradiation

OBJECTIVE: To determine the efficacy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in the detection of radiation-induced myocardial damage in beagles by comparing two pre-scan preparation protocols as well as to determine the correlation between abnormal myocardial FDG uptake and pathological findings. MATERIALS AND METHODS: The anterior myocardium of 12 beagles received radiotherapy locally with a single X-ray dose of 20 Gy. 18F-FDG cardiac PET/CT was performed at baseline and 3 months after radiation. Twelve beagles underwent two protocols before PET/CT: 12 hours of fasting (12H-F), 12H-F followed by a high-fat diet (F-HFD). Regions of interest were drawn on the irradiation and the non-irradiation fields to obtain their maximal standardized uptake values (SUVmax). Then the ratio of the SUV of the irradiation to the non-irradiation fields (INR) was computed. Histopathological changes were identified by light and electron microscopy. RESULTS: Using the 12H-F protocol, the average INRs were 1.18 +/- 0.10 and 1.41 +/- 0.18 before and after irradiation, respectively (p = 0.021). Using the F-HFD protocol, the average INRs were 0.99 +/- 0.15 and 2.54 +/- 0.43, respectively (p < 0.001). High FDG uptake in irradiation field was detected in 33.3% (4/12) of 12H-F protocol and 83.3% (10/12) of F-HFD protocol in visual analysis, respectively (p = 0.031). The pathology of the irradiated myocardium showed obvious perivascular fibrosis and changes in mitochondrial vacuoles. CONCLUSION: High FDG uptake in an irradiated field may be related with radiation-induced myocardial damage resulting from microvascular damage and mitochondrial injury. An F-HFD preparation protocol used before obtaining PET/CT can improve the sensitivity of the detection of cardiotoxicity associated with radiotherapy.