**1. Introduction**

#### **1.1. History of cardiac trauma**

The treatment of trauma to the heart has been written about since 3000 BC and had an inauspicious beginning. Until the late 19th century, the commonly held belief agreed with Boerhaave's sentiments that, "all penetrating cardiac trauma is fatal." Theodore Billroth warned, "The surgeon who should attempt to suture a wound of the heart would lose the respect of his colleagues." Paget believed that "surgery of the heart has probably reached the limits set by nature to all surgery: no new method of discovery can overcome the natural difficulties that attend a wound of the heart." However, reports of successful treatment of cardiac injuries began to surface toward the beginning of the 20th century. Like many surgical advances, times of war brought about new innovations and techniques for treating injuries.

Around the time of World War II, it was recognized that cardiac tamponade could be suc‐ cessfully managed by pericardiocentesis. With the advent of cardiopulmonary bypass by Gibbon in 1953, repair of more complex injuries became possible. This ushered in the modern era of treating injuries to the heart. Diagnosis of cardiac injury and tamponade has also been facilitated by portable ultrasound becoming the standard of care in the evaluation of trauma patients. The focused assessment with sonography for trauma (FAST) scan allows for simple, quick, and non-invasive assessment and recognition of cardiac trauma [1].

Cardiac trauma, especially penetrating injuries to the heart, still carries a very high mortality, but certainly is no longer considered uniformly fatal and attempt at repair is now the standard of care in patients presenting with signs of life upon arrival to the hospital[2, 3].

© 2013 Eiferman et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **2. Initial assessment and general assessment**

The initial care of the trauma patient with cardiac injuries does not vary from standard Advanced Trauma Life Support (ATLS) protocols. The primary priority is ensuring the patency of the airway and establishing adequate oxygenation and ventilation. This may include tube thoracostomy for drainage of hemothorax from the pleural space to allow re-expansion of the lung. Subsequently, the circulatory system is assessed. Priority is given to establishing intravenous access for the administration of crystalloid and/or blood products. If cardiac tamponade is suspected, this should be confirmed with sonographic confirmation of hemo‐ pericardium and/or right ventricular collapse during diastole[4]. If tamponade physiology is present, treatment for immediate drainage of the pericardial space should be initiated. This can be accomplished percutaneously by pericardiocentesis or via open pericardial window.

(systolic blood pressure less than 90 mm Hg) are taken directly to the operating room for exploration while patients with loss of vitals during transport or upon presentation to the

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If the diagnosis of penetrating cardiac injury is suspected but not confirmed, a subxiphoid pericardial window should be performed. Surgeons should be prepared to do a median sternotomy if an injury is identified in order to definitely address the wound. Upon opening the pericardial sac, any blood or fluid should be evacuated to allow the heart to properly fill and contract. The surgeon's finger can be used to apply pressure and temporarily control hemorrhage while further exposure is gained. This will also allow for replacement of blood

Repair of the myocardium should be done with interrupted sutures utilizing pledgets and performed in a horizontal mattress fashion [7, 8]. Injuries to small coronary arteries can be treated with simple ligation. Larger coronary arteries require either direct repair or bypass and the operating room should be capable of cardiopulmonary bypass (CPB).[7] Intracardiac

Whatever injury is encountered and method of repair utilized, the operative principles are

universal: relieve tamponade, stop the bleeding, and restore circulating volume. [8]

hospital are treated with Emergency Department thoracotomy.

**Figure 1.** Algorithm for the Management of Penetrating Cardiac Injury

volume and restoration of tissue perfusion.

injuries require CPB to be definitively addressed.

The treatment algorithm for cardiac injured patients branches at this point depending on the mechanism of injury and hemodynamic status. As is the standard in all trauma care, cardiac injuries are categorized as either blunt or penetrating and we will explore their assessment and treatment separately.

#### **3. Penetrating trauma**

Penetrating trauma to the heart most frequently occur with trauma to the anterior chest, but should also be suspected with wounds to the upper abdomen, chest, back, and neck [5]. Of the patients that do present to the hospital, the majority of the injuries are to the low pressure, anteriorly located right side of the heart (Table 1) [6]. Survival following penetrating trauma is often dependent on the state of the pericardial wound.[7] When the pericardial wound is open and blood is able to flow freely into the pleural space, the patient can often be supported with fluid resuscitation and chest tube thoracostomy. Persistent drainage from the thoracos‐ tomy tube should warn of possible cardiac injury and surgical exploration is indicated. Conversely, if the blood is retained in the pericardial space, cardiac tamponade and physiology will ensue if not drained immediately.


**Table 1.** Anatomic Location of Penetrating Cardiac Injuries

The protocol for treatment of patients with penetrating cardiac trauma can be further subdi‐ vided based upon the patient's vital signs upon presentation to the hospital (Figure 1). Management of the stable patient (systolic blood pressure greater than 90 mm Hg) allows for a more complete evaluation including chest x-ray and echocardiography. Unstable patients (systolic blood pressure less than 90 mm Hg) are taken directly to the operating room for exploration while patients with loss of vitals during transport or upon presentation to the hospital are treated with Emergency Department thoracotomy.

**Figure 1.** Algorithm for the Management of Penetrating Cardiac Injury

**2. Initial assessment and general assessment**

340 Principles and Practice of Cardiothoracic Surgery

and treatment separately.

**3. Penetrating trauma**

will ensue if not drained immediately.

Coronary Arteries Involved 3.1-4.4%

**Table 1.** Anatomic Location of Penetrating Cardiac Injuries

Right Atrium 14% Left Atrium 5% Right Ventricle 43% Left Ventricle 33%

The initial care of the trauma patient with cardiac injuries does not vary from standard Advanced Trauma Life Support (ATLS) protocols. The primary priority is ensuring the patency of the airway and establishing adequate oxygenation and ventilation. This may include tube thoracostomy for drainage of hemothorax from the pleural space to allow re-expansion of the lung. Subsequently, the circulatory system is assessed. Priority is given to establishing intravenous access for the administration of crystalloid and/or blood products. If cardiac tamponade is suspected, this should be confirmed with sonographic confirmation of hemo‐ pericardium and/or right ventricular collapse during diastole[4]. If tamponade physiology is present, treatment for immediate drainage of the pericardial space should be initiated. This can be accomplished percutaneously by pericardiocentesis or via open pericardial window.

The treatment algorithm for cardiac injured patients branches at this point depending on the mechanism of injury and hemodynamic status. As is the standard in all trauma care, cardiac injuries are categorized as either blunt or penetrating and we will explore their assessment

Penetrating trauma to the heart most frequently occur with trauma to the anterior chest, but should also be suspected with wounds to the upper abdomen, chest, back, and neck [5]. Of the patients that do present to the hospital, the majority of the injuries are to the low pressure, anteriorly located right side of the heart (Table 1) [6]. Survival following penetrating trauma is often dependent on the state of the pericardial wound.[7] When the pericardial wound is open and blood is able to flow freely into the pleural space, the patient can often be supported with fluid resuscitation and chest tube thoracostomy. Persistent drainage from the thoracos‐ tomy tube should warn of possible cardiac injury and surgical exploration is indicated. Conversely, if the blood is retained in the pericardial space, cardiac tamponade and physiology

The protocol for treatment of patients with penetrating cardiac trauma can be further subdi‐ vided based upon the patient's vital signs upon presentation to the hospital (Figure 1). Management of the stable patient (systolic blood pressure greater than 90 mm Hg) allows for a more complete evaluation including chest x-ray and echocardiography. Unstable patients If the diagnosis of penetrating cardiac injury is suspected but not confirmed, a subxiphoid pericardial window should be performed. Surgeons should be prepared to do a median sternotomy if an injury is identified in order to definitely address the wound. Upon opening the pericardial sac, any blood or fluid should be evacuated to allow the heart to properly fill and contract. The surgeon's finger can be used to apply pressure and temporarily control hemorrhage while further exposure is gained. This will also allow for replacement of blood volume and restoration of tissue perfusion.

Repair of the myocardium should be done with interrupted sutures utilizing pledgets and performed in a horizontal mattress fashion [7, 8]. Injuries to small coronary arteries can be treated with simple ligation. Larger coronary arteries require either direct repair or bypass and the operating room should be capable of cardiopulmonary bypass (CPB).[7] Intracardiac injuries require CPB to be definitively addressed.

Whatever injury is encountered and method of repair utilized, the operative principles are universal: relieve tamponade, stop the bleeding, and restore circulating volume. [8]

**Picture 1.** Cardiac Laceration from anterior stab woundPicture

**Figure 2.** Schematic Depiction of Right Ventricular Repair

Another form of penetrating cardiac injury that has increased in the modern era is iatrogenic injuries. As the fields of interventional and electrophysiology cardiology continue to increase the number of percutaneous procedures performed, there is a concomitant increase in iatrogenic injuries to the heart. Pacemaker and ICD placement, ASD occlusion devices, coronary catheterization, pericardiocentesis, and even central line placement can cause cardiac trauma. Usually the treatment is observational, but sometimes intervention is necessary. Fortunately these are rare complications but the incidence of iatrogenic injury has been reported as high as 6% for certain radiofrequency ablation procedures.[9] Awareness and

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prompt recognition of an injury are essential to successful treatment.

**3.1. Iatrogenic injuries**

**Picture 2.** Successful pledgeted repair

**Figure 2.** Schematic Depiction of Right Ventricular Repair

#### **3.1. Iatrogenic injuries**

**Picture 1.** Cardiac Laceration from anterior stab woundPicture

342 Principles and Practice of Cardiothoracic Surgery

**Picture 2.** Successful pledgeted repair

Another form of penetrating cardiac injury that has increased in the modern era is iatrogenic injuries. As the fields of interventional and electrophysiology cardiology continue to increase the number of percutaneous procedures performed, there is a concomitant increase in iatrogenic injuries to the heart. Pacemaker and ICD placement, ASD occlusion devices, coronary catheterization, pericardiocentesis, and even central line placement can cause cardiac trauma. Usually the treatment is observational, but sometimes intervention is necessary. Fortunately these are rare complications but the incidence of iatrogenic injury has been reported as high as 6% for certain radiofrequency ablation procedures.[9] Awareness and prompt recognition of an injury are essential to successful treatment.

**Figure 3.** Pledgets are used to reinforce the suture line

#### **3.2. Cardiac fistulas**

Although hemorrhage and tamponade are the most common injuries seen in penetrating cardiac trauma, cardiac fistulas are another uncommon yet dramatic complication from cardiac trauma (including iatrogenic injuries). Fistulous connections can occur between coronary arteries, aorta, and directly with the cardiac chambers. Patients, if symptomatic, usually present with congestive heart failure and surgical repair is usually required.[10, 11]. Presen‐ tation is variable from acutely after the injury to decades post-injury. Echocardiography and coronary angiography are the cornerstones of diagnosis and necessary to plan surgical repair. **4. Blunt injury**

**4.1. Background (mechanism, incidence, and pathophysiology)**

Philadelphia, WB Saunders Co, 1989, p 42. Used by permission.)

Blunt cardiac injury (BCI) is a spectrum of traumatic heart diseases with severity that can range from myocardial contusion and EKG changes to septal rupture and death. Earlier in the century, cardiac contusion or concussion were terms used to diagnose cardiac changes from blunt thoracic trauma. More recently, BCI is the term used to better incorporate and classify

**Figure 4.** Various maneuvers used to repair penetrating wounds of the heart. Suturing of cardiac wound underneath the wound-occluding finger (A). Wound sutured (A'). Placement of horizontal mattress sutures through the myocardi‐ um underneath the cardiac wound-occluding finger and underneath the coronary artery adjacent to the wound (B). Wound sutured (B'). Control of atrial bleeding with a vascular clamp (C). (From Symbas PN: Cardiothoracic Trauma.

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**Figure 4.** Various maneuvers used to repair penetrating wounds of the heart. Suturing of cardiac wound underneath the wound-occluding finger (A). Wound sutured (A'). Placement of horizontal mattress sutures through the myocardi‐ um underneath the cardiac wound-occluding finger and underneath the coronary artery adjacent to the wound (B). Wound sutured (B'). Control of atrial bleeding with a vascular clamp (C). (From Symbas PN: Cardiothoracic Trauma. Philadelphia, WB Saunders Co, 1989, p 42. Used by permission.)
