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.

Evolución del traumatismo penetrante cardíaco operado / Penetrating cardiac injury: evolution of characteristics, severity and mortality in surgery treated patients

Resumen Introducción: El traumatismo penetrante cardíaco (TPC) es una lesión poco frecuente y con alta morbilidad y mortalidad. Objetivo: Analizar la evolución de características clínicas, anatómicas, gravedad, morbilidad y mortalidad de pacientes operados por TPC. Materiales y Métodos: Estudio analítico de pacientes tratados quirúrgicamente por TPC en Hospital Clínico Regional "Dr. Guillermo Grant Benavente", Concepción, Chile. Se analizaron los periodos: enero-1990 a diciembre-2004 y enero-2005 a diciembre-2019. Se comparó: sexo, edad, lesiones asociadas, agente y mecanismo del traumatismo, comportamiento fisiopatológico, ubicación anatómica de la lesión, clasificaciones del traumatismo cardíaco Attar, Saadia y OIS-AAST, IGT (índices de gravedad del traumatismo): ISS, RTS-T y TRISS, morbilidad y mortalidad según periodos. Se realizó análisis estadístico con SPSS25®, se utilizaron las pruebas chi-cuadrado, exacta de Fisher y Mann-Whitney. Se consideró significativo un valor p < 0,05. Resultados: Total 235 TPC, 112 en el primer periodo y 123 en el segundo. Mecanismo arma blanca en 96 (85,7%) y 104 (84,6%) según periodos. En el segundo periodo se observó un aumento de lesiones extratorácicas asociadas, paro cardiorrespiratorio y lesión de ubicación izquierda. Las clasificaciones del traumatismo cardíaco y los IGT ISS, RTS-T y TRISS mostraron mayor gravedad y probabilidad de muerte en los pacientes del segundo periodo. La mortalidad no mostró diferencias: 14 (12,5%) y 14 (11,4%) según periodos (p = 0,792). Discusión: En nuestra serie los pacientes tratados por TPC han evolucionado hacia un perfil de mayor gravedad tanto en parámetros fisiológicos como anatómicos. La mortalidad se ha mantenido estable a través del tiempo.

Background: Penetrating cardiac injury (PCI) is a rare injury with high morbidity and mortality. Aim: To analyze the evolution of clinical and anatomical characteristics, severity, morbidity and mortality of patients operated on by PCI. Materials and Methods: Analytical study of patients surgically treated for PCI at the "Guillermo Grant Benavente" Regional Clinical Hospital, Concepción, Chile. Two periods were analyzed: January-1990 to December-2004 and January-2005 to December-2019. Sex, age, associated injuries, trauma agent and mechanism, pathophysiological behavior, anatomic location of the injury, classifications of cardiac trauma: Attar, Saadia and OIS-AAST, TSI (trauma severity indices): ISS, RTS-T and TRISS, morbidity and mortality were compared according to periods. Statistical analysis was performed with SPSS25®, the chi-square, Fisher exact and Mann-Whitney tests were used. A p value < 0.05 was considered significant. Results: Total 235 PCI, 112 in the first period and 123 in the second. Stab as mechanism in 96 (85.7%) and 104 (84.6%) according to periods. An increase in associated extra thoracic injuries, cardiorespiratory arrest, and injury to the left location were observed in the second period. The cardiac trauma classifications and the TSI ISS, RTS-T and TRISS showed greater severity and probability of death in the second period patients. Mortality did not show differences: 14 (12.5%) and 14 (11.4%) according to periods, p = 0.792. Discussion: In our series, patients treated with PCI have evolved towards a more severity profile in both, physiological and anatomical parameters. Mortality has been stable over time.

Trauma cardiaco en pediatría / Cardiac trauma in pediatrics

El trauma cardiaco constituye una entidad infrecuente en pediatría que requiere de toma de decisiones rápidas y oportunas, además de un manejo óptimo para obtener una mejor sobrevida de los pacientes. En esta revisión en base a un caso clínico, se actualiza el tema de trauma cardiaco, se describen los tipos más frecuentes, las diferentes formas clínicas de presentación y el enfrentamiento terapéutico. Palabras clave: Trauma cardiaco, penetrante cardiaca, cirugía cardiaca.

Cardiac trauma is an uncommon entity in pediatrics that requires quick and timely decision making, as well as optimal management to obtain a better survival of patients. In this review based on a case report, the issue of cardiac trauma is updated, the most frequent types, the different clinical forms of presentation and the therapeutic confrontation are described.

Ruptura traumática de músculo papilar da valva tricúspide com forame oval patente adquirido e ruptura atrial direita oculta / Traumatic tricuspid valve papillary muscle case with concomitant acquired patent foramen ovale and covert right atrial rupture

RESUMO O traumatismo cardíaco é comum em acidentes com veículos automotores. Uma mulher com 50 anos de idade foi transportada para nosso hospital após sofrer múltiplos traumatismos em um acidente de automóvel quando dirigia em alta velocidade. Após admissão à unidade de terapia intensiva, uma ultrassonografia cardíaca revelou ruptura traumática de músculo papilar da valva tricúspide e forame oval patente, enquanto se observou, no exame físico, o sinal de Lancisi. Foi realizado tratamento cirúrgico com anuloplastia da valva e fechamento do forame oval patente; durante o ato cirúrgico, diagnosticou-se ruptura oculta do átrio direito.

ABSTRACT Cardiac trauma often occurs in motor vehicle accidents. A 50-year-old female driver was transported to our hospital with multiple trauma after a high-speed car accident. After admission to the intensive care unit, cardiac ultrasound examination revealed traumatic tricuspid valve papillary muscle rupture and patent foramen ovale, while Lancisi's sign was noted on physical examination. Surgical treatment was performed with valve annuloplasty and closure of the patent foramen ovale and a covert right atrial defect that was detected intraoperatively.

Traumatismo penetrante cardiaco: caracterización, resultados inmediatos y variables asociadas a morbilidad y mortalidad en pacientes operados / Penetrating cardiac trauma: findings, outcomes and prognostic factors in operated patients

INTRODUCCIÓN: El traumatismo penetrante cardiaco (TPC) por sus características y en particular por su alta mortalidad, constituye un desafío quirúrgico permanente. OBJETIVOS: Describir las características, resultados inmediatos y factores pronósticos en TPC. MATERIALES Y MÉTODO: Estudio descriptivo transversal, revisión de protocolos prospectivos de traumatismo torácico, registros de pabellón y fichas clínicas. Período enero de 1990-diciembre de 2017. Se incluyeron todos los pacientes con TPC operados. Se describen y analizan diversas variables. Se realizó regresión logística con análisis univariado y multivariado para identificar variables asociadas a morbilidad, deterioro neurológico y mortalidad. RESULTADOS: 220 pacientes operados por TPC, 209 (95,0%) hombres, edad promedio 30,4 ± 13,3, mediana 27 años. Mecanismo: agresión en 202 (91,8%). El agente traumático fue en 186 (84,5%) arma blanca, en 21 (9,5%) arma de fuego. Presentaban taponamiento 169 (76,8%) pacientes, ingresaron en shock 103 (46,8%) y en paro cardiorrespiratorio 20 (9,1%). Vía de abordaje fue esternotomía en 157 (71,4%), toracotomía izquierda en 58 (26,4%). Las cavidades cardiacas lesionadas más frecuentes fueron ventrículo derecho en 110 (50,0%), ventrículo izquierdo en 72 (32,7%). Se hospitalizaron en UCI en el postoperatorio 135 (61,4%), se transfundieron 74 (33,6%), presentaron complicaciones 60 (27,3%) y se reoperaron 21 (9,5%). Mortalidad 28 (12,7%). La estadía postoperatoria tuvo una mediana de 6 días (rango 1-150). Se identificaron factores pronósticos. DISCUSIÓN: Los TPC operados son más frecuentes en hombres agredidos con arma blanca, la cavidad lesionada más frecuente es el ventrículo derecho. Nuestra morbimortalidad es comparable con series internacionales.

INTRODUCTION: Penetrating cardiac trauma (PCT) constitute a permanent surgical challenge due to it characteristics and high mortality. AIM: To describe the findings, outcomes and prognostic factors in PCT. MATERIAL AND METHOD: Cross-sectional descriptive study, review of prospective thoracic trauma protocols and surgical registries. Period January 1990-December 2017. All patients with PCT were included. Various variables are described and analyzed. Univariate and multivariate analysis were performed to identify factors associated with morbidity, neurologic dysfunction and mortality. RESULTS: 220 patients PCT, 209 (95.0%) men, mean age 30.4 ± 13.3, median 27 years. Mechanism: Aggression in 202 (91.8%). The traumatic agent was cold steel in 186 (84.4%) and fire arm in 21 (9.5%). 169 (76.8%) patients presented with tamponade, 103 (46.8%) shock and 20 (9.1%) cardiopulmonary arrest. Approach was sternotomy in 157 (71.4%), left thoracotomy in 58 (26.4%). The most common injured areas were right ventricle in 110 (50.0%), left ventricle in 72 (32.7%). 135 (61.4%) patients needed postoperative ICU and 74 (33.6%) were transfused. Complications occurred in 60 (27.3%). Twenty-one (9.5%) were reoperated. Mortality 28 (12.7%). The postoperative median stay was 6 days (Range 1-150). Prognostic factors were identified. DISCUSSION: Operated PCT are more frequent in men with stab wound, the most common injured area is the right ventricle. The morbidity and mortality is comparable with international series.

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.

The role of heart team approach in penetrating cardiac trauma: case report and review of the literature

Abstract Penetrating cardiac trauma has been increasing in clinical experience and is joined to important morbidity and mortality. A case of a 38-year-old female with history of postpartum depression was reported, admitted to our department for cardiac tamponade due to penetrating self-inflicted multiple stab wound of the chest complicated by rupture of anterior left ventricular wall and traumatic ventricular septal defect. Following the unstable hemodynamic instability, a combined therapeutic strategy was chosen: surgery and transcatheter implantation to correct free wall ventricle damage and traumatic ventricular septal defect, respectively.

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.

Heridas penetrantes cardíacas: comentario a propósito de una publicación de 1945 / Penetrating heart wounds: comments about a 1945 publication

A raíz de una publicación de 1945, se realiza una revisión acerca de las heridas penetrantes cardíacas: Los conceptos que han resistido el paso del tiempo, los que han cambiado, y las nuevas tendencias. Se compara con la publicación de hace 70 años y se ofrecen algunas conclusiones...

Following a 1945 publication, a brief review about penetrating heart wounds is performed: The concepts that have stood the test of time, those have changed, and the new trends. We compare with the publication of 70 years ago and offer some conclusions...

Emergent cardiopulmonary bypass during pectus excavatum repair.

Pectus excavatum is a chest wall deformity that produces significant cardiopulmonary disability and is typically seen in younger patients. Minimally invasive repair of pectus excavatum or Nuss procedure has become a widely accepted technique for adult and pediatric patients. Although it is carried out through a thoracoscopic approach, the procedure is associated with a number of potential intraoperative and post-operative complications. We present a case of cardiac perforation requiring emergent cardiopulmonary bypass in a 29-year-old male with Marfan syndrome and previous mitral valve repair undergoing a Nuss procedure for pectus excavatum. This case illustrates the importance of vigilance and preparation by the surgeons, anesthesia providers as well as the institution to be prepared with resources to handle the possible complications. This includes available cardiac surgical backup, perfusionist support and adequate blood product availability.

Percutaneous closure of a post-traumatic ventricular septal defect with a patent ductus arteriosus occluder

OBJECTIVE: Ventricular septal defects resulting from post-traumatic cardiac injury are very rare. Percutaneous closure has emerged as a method for treating this disorder. We wish to report our experience in three patients who underwent percutaneous closure of a post-traumatic ventricular septal defect with a patent ductus arteriosus occluder. METHODS: We treated three patients with post-traumatic ventricular septal defects caused by stab wounds with knives. After the heart wound was repaired, patient examinations revealed ventricular septal defects with pulmonary/systemic flow ratios (Qp/Qs) of over 1.7. The post-traumatic ventricular septal defects were closed percutaneously with a patent ductus arteriosus occluder (Lifetech Scientific (Shenzhen) Co., LTD, Guangdong, China) utilizing standard techniques. RESULTS: Post-operative transthoracic echocardiography revealed no residual left-to-right shunt and indicated normal ventricular function. In addition, 320-slice computerized tomography showed that the occluder was well placed and exhibited normal morphology. CONCLUSION: Our experiences indicate that closure of a post-traumatic ventricular septal defect using a patent ductus arteriosus occluder is feasible, safe, and effective.

Understanding traumatic blunt cardiac injury.

Cardiac injuries are classified as blunt and penetrating injuries. In both the injuries, the major issue is missing the diagnosis and high mortality. Blunt cardiac injuries (BCI) are much more common than penetrating injuries. Aiming at a better understanding of BCI, we searched the literature from January 1847 to January 2012 by using MEDLINE and EMBASE search engines. Using the key word "Blunt Cardiac Injury," we found 1814 articles; out of which 716 articles were relevant. Herein, we review the causes, diagnosis, and management of BCI. In conclusion, traumatic cardiac injury is a major challenge in critical trauma care, but the guidelines are lacking. A high index of suspicion, application of current diagnostic protocols, and prompt and appropriate management is mandatory.

Trauma penetrante cardiaco tratado en el Hospital Territorial Docente Pedro Betancourt, Municipio Jovellanos, 2004: reporte de un caso / Penetrating cardiac trauma treated at the teaching Territorial Hospital Pedro Betancourt, Municipality of Jovellanos, 2004: report of a case

Los traumas penetrantes cardiacos constituyen uno de los cuadros más dramáticos que pueden presentarse en la sala de urgencia por su alta letalidad, sólo un rápido traslado al centro asistencial, un diagnóstico precoz y una toracotomía de urgencia, puede aumentar la supervivencia. Se presentó un paciente operado en el Hospital Territorial Docente Pedro Betancourt, de Jovellanos, en mayo del 2004, de una herida ventricular izquierda, logrando su supervivencia...

Penetrating cardiac trauma is one of the most dramatic features that could assist the urgency service because of its high lethality. Only a fast delivery of the patient to a health care institution, a precocious diagnostic and an urgent thoracotomy might increase survival. We present a patient operated in the Teaching Territorial Hospital Pedro Betancourt, Jovellanos, in May 2004, for a left ventricular injury, achieving his survival...

Ferimento cardíaco transfixante por projétil de arma de fogo: relato de caso / Transfixing gunshot wound to the heart: case report

O trauma cardíaco penetrante apresenta altas taxas de mortalidade. É comumente associado a lesões por armas brancas, porém crescentes índices na violência urbana têm contribuído para o aumento no número de ferimentos cardíacos por projéteis de armas de fogo. Estas possuem as maiores taxas de mortalidade dentre os ferimentos cardíacos penetrantes e podem acometer múltiplas câmaras cardíacas, com índices de mortalidade ainda mais elevados. Apresentamos um caso de um paciente, vítima de tentativa de roubo, que sofreu ferimento cardíaco transfixante por projétil de arma de fogo, operado com sucesso em nossa instituição.

Penetrating cardiac trauma carries high mortality rates. It has been commonly associated with stabbing, but increasing urban violence has led to growing numbers of gunshot heart wounds. The latter have higher mortality rates among penetrating cardiac injuries and may affect multiple heart chambers, with mortality rates even higher. We report a patient, victim of an attempted armed robbery, who had a transfixing gunshot wound to the heart, successfully operated at our institution.

Análise epidemiológica das pericardiotomias realizadas em um hospital universitário de Curitiba / Epidemiological analysis of pericardiotomys held in a university hospital of Curitiba

OBJETIVO: Analisar epidemiologicamente a utilização da janela pericárdica(JP) no diagnóstico de lesão cardíaca em um hospital universitário de trauma de Curitiba. MÉTODOS: Estudo observacional, retrospectivo, de análise dos prontuários de pacientes que foram submetidos a pericardiotomia por trauma contuso ou penetrante, no período de seis anos, no serviço de Urgência e Emergência do Hospital Universitário Cajuru. RESULTADOS: 120 pacientes foram submetidos à Janela Pericárdica no período acima referido. A faixa etária variou de 15 a 80 anos, sendo a maior prevalência entre os 20 a 30 anos (49,7 por cento), 105(87,5 por cento) pacientes eram homens e 15(12,5 por cento) mulheres. Os traumas fechados foram 14(11,67 por cento) e penetrantes 105(87,5 por cento). Dos penetrantes, 41 foram por ferida de arma branca, 60 por ferida de arma de fogo e quatro por ambas. Quanto à localização das lesões: 47,5 por cento foram precordiais, 34,16 por cento em transição tóraco-abdominal, 5,0 por cento em ambas e 13,33 por cento em outras localizações. Das JP realizadas, 72,5 por cento foram negativas e 27,5 por cento positivas. Dentre as positivas, as lesões cardíacas encontradas foram: átrio direito 21,2 por cento, ventrículo direito 30,3 por cento, ventrículo esquerdo 24,2 por cento, aorta ascendente 3 por cento, nenhuma lesão 21,2 por cento. Houve 35 óbitos: 18 deles até 24hs e 17 após 24hs. CONCLUSÃO: A janela pericárdica foi mais realizada em homens jovens com ferimentos penetrantes por arma de fogo, em sua maioria com lesão do ventrículo direito como principal achado, concordando com a literatura revisada.

OBJECTIVE: Epidemiologically analyze the use of the pericardiostomy in the diagnosis of cardiac injury in a trauma universitary hospital in Curitiba. METHODS: Observacional, retrospective study, analyzing medical records of patients who were submitted to penetrating or blunt trauma, in a period of 06 years, in Urgency and Emergency unit of Cajuru Universitary Hospital. RESULTS: 120 patients had been submitted to pericardiostomy in the period above related. The age group varied from 15 to 80 years, the major prevalence between 20 and 30 years (49.7 percent), 105 patients were men and 15 women. Blunt trauma corresponded to 14 patients and penetrating to 105 patients. From penetrating ones, 41 patients were inflicted by stabwound, 60 by gunshot wound and 4 by both. About injury sites: 47.5 percent had been precordial, 34.16 percent in thoraco-abdominal transistion, 5.0 percent in both and 13.33 percent in other sites. From the accomplished JP, 72.5 percent had been negative and 27.5 percent positive. Among the positive, cardiac injuries diagnosed by immediate thoracotomy were: right atrium 21.2 percent, right ventricle 30.3 percent, left ventricle 24,2 percent, ascending aorta 3 percent, no injury 21.2 percent. 35 patients died: 18 of them up to 24hs and 17 after 24hs. CONCLUSION: The pericardiostomy were performed mostly in young men with penetrating trauma caused by gunshot wounds., in its majority with injury of the right ventricle as main finding, which agreed to the reviwed literature.

Cierre espontáneo de fístula residual post cierre quirúrgico de fístula aorto-ventricular derecha traumática: Caso clínico / Spontaneous closure of a residual fistula after surgical closure of a traumatic aorto-right ventricular fístula: Report of one case

We report a 16-year-old boy, who suffered a right vent ride penetrating injury caused by a sharp blade that evolved to cardiac tampon. He underwent surgery and was discharged four days later. Thirteen days later, a cardiac murmur was found. An echocardiography showed an aorta-right ventricular fistula. Surgical closure was performed through an aortotomy on cardiopulmonary by pass. The control echocardiography showed a small residual fistula, which closed spontaneously three months later.

Management of penetrating heart and accompanying lung injuries

Penetrating heart injury is potentially a life threatening condition due to cardiac tamponade or exsanguinating hemorrhage. The aim of this study was to evaluate victims who were referred to our hospital with penetrating heart and accompanying lung injuries and to review our overall outcome with this type of combined injuries. Twenty patients with combined penetrating heart and lung injuries were operated at Yuzuncu Yil University Research Hospital, between May 1999 and January 2010. The diagnosis of combined heart and lung injuries was proved by surgical exploration in all cases. The surgical procedures mainly included the relief of cardiac tamponade, control of bleeding, repair of cardiac and pulmonary lacerations, and coronary artery bypass grafting if required. In this series of 20 patients; there were 18 males and two females between the age of 14 to 60 years, with a mean age of 34.8 +/- 13.5 years. Seventeen victims sustained stab wounds, and the remaining three were injured by a gunshot wounds. In 20 patients there were 22 cardiac chamber injuries. The most commonly injured cardiac chamber was the right ventricle followed by the left ventricle. In addition to the injuries to heart muscle, injuries to the coronary arteries were found in two patients. The most commonly injured lung lobe was the left upper lobe. Our experience shows that early diagnosis and immediate surgical intervention are the main factors affecting patient survival after penetrating heart and lung injuries. Therefore, heart injury should always be kept in mind in victims with penetrating thoracic injuries