Ventricular Repair 

Ventricular repair, or cardiorrhaphy, has long been one of the most dramatic and lifesaving procedures performed in the emergency department (ED). Around 3000 BCE, in the Edwin Smith Surgical Papyrus, the first reports of trauma to the thorax were described.[1]  The first successful human cardiorrhaphy was performed by the German physician Rehn in 1896 to repair a right ventricular injury sustained during a fencing match.[2]

The first successful cardiorrhaphy in the United States was performed by Hill in 1902; he operated on a teenage stabbing victim on a kitchen table in Montgomery, Alabama.[3]  This began the practice of emergency cardiac repair in patients who sustain life-threatening penetrating trauma to the heart.

Cardiac trauma is divided into two mechanisms, as follows:

• Blunt injuries - Cardiac rupture following blunt thoracic trauma usually causes death at the scene and is not typically encountered clinically ^{[4, 5, 6]}
• Penetrating injuries - These are also commonly lethal but can be salvageable; the most common causes of death from penetrating trauma wounds are  cardiac tamponade and exsanguination; in contradistinction to other forms of trauma, preoperative resuscitation plays a limited role, and immediate surgical intervention is a superior determinant of survival ^{[7, 8, 9, 10, 11, 12, 13]}

Consider cardiac injury in the differential whenever penetrating injury has occurred in the thorax or upper abdomen. The area of most concern is known as the cardiac box. This is an area of the trunk in which penetrating injuries risk damage to the heart. Anatomically, it is a triangular region bordered by the midclavicular lines laterally, the clavicles superiorly, and the costal margins inferiorly.[7]

Clinical presentations can vary widely, from hemodynamically stable to cardiac arrest. Cardiac tamponade is commonly thought to correlate with the Beck triad (hypotension, elevated jugular venous pressure, and muffled heart sounds), but these symptoms are found only in a minority of patients. Signs of shock (eg, tachycardia, hypotension, diaphoresis, and agitation) are better correlated with tamponade and should, therefore, be assessed.[7]

The chest radiograph does not commonly show an enlarged cardiac silhouette, even in the setting of acute tamponade. In cases of suspected penetrating cardiac injury, radiography should be used to assess for clues of cardiac injury, including retained intracardiac foreign bodies, hemothorax, pneumothorax, or pneumoperitoneum.[7, 14, 15]  For more information, see Pneumothorax Imaging. (See the image below.)

A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the pleural line.

The FAST (Focused Assessment with Sonography in Trauma) examination is increasingly popular as the diagnostic tool of choice in the ED for identifying pericardial effusions. It does have its limitations, however, in that it is both operator- and patient-dependent. It should be used primarily to direct and prioritize management.[16]

An essential part of the management of patients in extremis from cardiac injury is thoracotomy for cardiac resuscitation,[17] and possible cardiorrhaphy. The thoracotomy involves making a large incision to expose the heart, aorta and hilum. It allows for internal defibrillation and cardiac massage. Once the heart is exposed, a pericardial incision can be made to release any tamponade. The heart is then examined to look for any penetrating wounds. For a detailed description of this procedure, see Emergency Bedside Thoracotomy.

Multiple methods are used in the emergency management of cardiac wounds, including the following:

• Digital pressure - This method is used for small wounds and can be used to control bleeding on the way to the operating room (OR)
• Foley catheter: For larger wounds, a Foley catheter can be inserted through the wound and inflated, and with gentle traction, tamponade can be accomplished; placing a Foley catheter can also stop hemorrhage so that cardiorrhaphy can be performed or a patient can be transported to the OR for repair; an additional advantage of using the Foley catheter is the ability to administer intracardiac medications, fluids, or blood ^{[18, 19]}
• Immediate cardiorrhaphy (in the ED) - This method has been found to yield a survival rate up to 31% in patients presenting with penetrating cardiac injuries ^[16]

The science of surgical resuscitation has advanced tremendously since Rehn performed the first human cardiorrhaphy. The popularity of this procedure has waxed and waned as a result of changes in surgical techniques and differing analyses of patient outcome data. Currently, the indications for emergency thoracotomy, with or without cardiorrhaphy, include the following:

• Cardiac arrest in patients with penetrating chest trauma in whom signs of life (ie, palpable pulse, pupillary response, spontaneous ventilatory effort) were present at the scene or in the ED ^{[20, 21]}
• Persistent hypotension or signs of cardiac tamponade in the setting of penetrating chest trauma
• Cardiac arrest in the ED, in the setting of blunt trauma

Contraindications for verntricular repair include the following:

• Clinically stable patient
• Blunt trauma in patients with no signs of life upon arrival ^[22]
• Patient with evidence of prolonged death (eg, rigor mortis, livor mortis)
• Patient whose life is unsalvageable (eg, decapitation)

The thoracotomy tray should include the following:

• Sterile preparatory tray
• Scalpel, No. 10 or No. 20
• Mayo or Metzenbaum scissors
• Rib spreader
• Tissue forceps (2)
• Satinsky vascular clamps (2)
• Lebsche knife
• Hegar needle holders (3)
• Nylon (3-0) or polypropylene (2-0) suture on a curved needle
• Teflon pledgets
• Suture scissors
• Surgical stapler
• Sterile towels
• Sponges
• Foley catheter
• Chest tube
• Towel clips

Anesthesia

Always attend to the ABCs (Airway, Breathing, Circulation), particularly in trauma patients. Ideally, intubate patients prior to thoracotomy or cardiorrhaphy. If that is not possible, intubate during the procedure. Administer general anesthesia using rapid sequence intubation protocols and postintubation sedation, analgesia, or paralysis. For more information, see Tracheal Intubation, Rapid Sequence Intubation and Tracheal Intubation, Medications.

Local anesthesia is not feasible and may cause life-threatening arrhythmias, as the maximum dose of lidocaine may be exceeded for a thoracotomy incision. Observe the patient for signs of pain or agitation (eg, tachycardia or tachypnea). Choose appropriate sedative and neuromuscular blocking agents to maintain both cardiovascular output and effective anesthesia.

Positioning

Place the patient in a supine position with the left anterior chest wall exposed. Place the patient’s left arm above the head, and place a rolled towel or sheet under the left side for optimal exposure and to ensure a wide incision.

Prepare the left anterior chest wall with povidone-iodine solution and sterile towels. Note, however, that preprocedural antiseptic skin preparation may be ineffective and may delay the procedure.[23]

Penetrating trauma to the chest in an unstable patient is an indication for thoracotomy[17] and possible cardiorrhaphy.

The ventricles are involved in 80% of penetrating cardiac wounds.

Once a cardiac wound is identified, hemostasis should be obtained quickly with a finger or Foley catheter while closure materials are prepared.

Surgical staples may be a faster and safer closure method than the traditional approach using suture with pledgets.

Make an incision in either the fourth or fifth intercostal space. In men, this location corresponds to the area inferior to the nipple; in women, the inframammary fold can be used as a landmark. The breast may have to be retracted in women in order to expose this area.

The incision should begin just lateral to the sternum on the left and continue to the midaxillary line. Take care to confine the incision to the inferior border of the intercostal space throughout its course. This ensures wide exposure with the rib spreader through a single intercostal space and decreases the possibility of injuring the neurovascular bundle, which courses over the inferior border of the upper rib. (See the image below.)

Primary incision in the fourth or fifth intercostal space.

The initial incision should be deep enough to cut through the pectoralis major and serratus muscles. The intercostal muscles can be bluntly dissected with the end of the scalpel or scissors. Once the pleura is exposed, make an initial opening with the scalpel. Use the scissors to open the pleura along its length from the scalpel opening, taking care to avoid injury to underlying intrathoracic structures. (See the image below.)

Open the pleura with scissors.

Insert the rib spreader in its closed position through the intercostal incision. Crank the handle to separate the blades and open the chest. Open the chest widely enough to allow easy access to the mediastinum. (See the image below.)

Chest opened with rib spreader.

Identify the pericardium, and make a longitudinal opening in the pericardial sac anterior to the phrenic nerve. Avoid the phrenic nerve, which runs vertically along the lateral border. If cardiac tamponade is present, a gush of blood ensues after the initial opening is made. Use the fingers to tear the pericardium longitudinally, opening it along its length. Remove any clots or remaining blood within the pericardium. (See the image below.)

Initial opening of the pericardium with the scalpel.

Inspect the heart for obvious lacerations, and quickly identify the coronary arteries. Current data suggest that the incidence of chamber laceration in penetrating cardiac injury is as follows: 40% right ventricle (RV), 40% left ventricle (LV), 24% right atrium (RA), and 3% left atrium (LA).[1]

Once the laceration is isolated, several methods exist for temporary hemostasis. If the laceration is small enough, a finger may be placed at the site of the laceration while suture is prepared. Lacerations to the atria can be controlled with Satinsky vascular clamps. Alternatively, if the laceration is large, a Foley catheter may be placed through the wound and the balloon inflated. The catheter should be retracted until resistance is met to seal the wound. Medications may be administered through the Foley catheter into the intracardiac space. (See the image below.)

Locate the laceration.

Once a laceration is found, simple suturing with a monofilament material (eg, 2-0 polypropylene) can be performed in a continuous or interrupted fashion.[1]  However, suturing of cardiac wounds over pledgets is the time-honored technique. Because of its time-consuming and complicated nature, however, most authors do not recommend this in the emergency department (ED).[1]  To begin the cardiorrhaphy procedure with pledgets, thread nylon suture through the Teflon pledget, and place a horizontal mattress suture across the laceration. (See the image below.)

Suture threading.

Thread the suture through another Teflon pledget on the opposite wound edge, and complete the mattress stitch. (See the image below.)

Completed mattress stitch.

The pledgets prevent further injury to an already friable myocardium. Repeat the suture step until the laceration is sufficiently approximated. Take care to avoid the coronary arteries; a suture placed into or over these arteries can have disastrous consequences.[24, 25, 26]  (See the image below.)

Sufficiently approximated laceration.

In cardiorrhaphy, surgical staples are an excellent alternative to suture with pledgets. They are quicker and equally effective. Animal studies demonstrate that the use of surgical staples reduces time to wound closure and has similar repair integrity.[27, 28]  This method also reduces the risk of exposure to contaminated needles in the setting of an ED thoracotomy. These findings have been demonstrated in the clinical setting as well.[29]

Potential complications of ventricular repair include the following:

• Injury to underlying thoracic structures, including the lung, heart, great vessels, coronary arteries, thoracic duct, esophagus, and phrenic nerve
• Uncontrolled hemorrhage ^[26]
• Postpericardiectomy syndrome (evidenced by fever, chest pain, pericardial effusion, pericardial rub, and elevated ST segments on electrocardiography [ECG]) ^[30]
• Dysrhythmias
• Physician and ancillary staff exposure to infectious blood and tissue (eg,  HIV,  hepatitis B,  hepatitis C) ^[23]
• Serious infection in the setting of ED thoracotomy (uncommon) ^[23]