ARTICLE IN PRESS doi:10.1510/icvts.2007.156372
Interactive CardioVascular and Thoracic Surgery 6 (2007) 577–578 www.icvts.org
Case report - Cardiac general
Surgical management of penetrating cardiac injuries using a fibrin glue sheet Koichi Toda*, Masao Yoshitatsu, Hironori Izutani, Katsuhiko Ihara Division of Cardiovascular Surgery, National Kure Medical Center, Hiroshima, Japan Received 22 March 2007; received in revised form 30 April 2007; accepted 30 April 2007
Abstract A penetrating cardiac injury is among the most lethal of all injuries. We present a case of penetrating cardiac injuries to both ventricles. A laceration on the right ventricle was repaired using buttressed sutures, while an injury to the left ventricle was repaired using a collagen mesh dressing covered by fibrin glue (TachoComb patch) without employing cardiopulmonary bypass. The patient recovered uneventfully without a ventricular pseudoaneurysm. Our results demonstrate the usefulness of a TachoComb patch for penetrating cardiac injuries occurring adjacent to the large coronary artery in the posterior wall of the heart. 䊚 2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Penetrating cardiac injury; Biologic glue; Pneumopericardium
1. Introduction A penetrating cardiac injury is among the most lethal of all injuries. In a review of 1198 cases of penetrating cardiac injuries, only 6% of the patients arrived at the hospital alive w1x. Prompt diagnosis and emergency surgery play a crucial role to save these critically ill patients. Herein, we present a case of penetrating cardiac injuries to the right and left ventricles (LV), which were successfully repaired using buttress sutures and a collagen mesh dressing covered by fibrin glue (TachoComb patch). 2. Case A 50-year-old man was found in shock after attempted suicide by stabbing himself with a 30-cm long Sashimi-knife and was transported to our emergency room. Upon arrival, the patient was not alert and his vital signs were blood pressure of 70y40 mmHg, heart rate of 120 beatsymin, and respiratory rate of 36ymin. Three stab wounds were found, the first had penetrated through the neck, the second was in the 4th intercostal space, and the third was in the right upper quadrant. An echocardiogram in the emergency room showed a left hemothorax and ruled out cardiac tamponade. Fluid resuscitation improved the hemodynamics and he was sent to computed tomography (CT), which demonstrated intraperitoneal blood around the liver, a pneumopericardium, and a left hemothorax (Fig. 1). The patient was immediately taken to the operating room for exploration of cardiac injury. *Corresponding author. Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization, Osaka Rosai Hospital, 1179-3, Nagasonecho, Kita-ku, Sakai, Osaka, Japan. Tel.: q81-72-252-3561; fax: q81-72-2553349. E-mail address:
[email protected] (K. Toda). 䊚 2007 Published by European Association for Cardio-Thoracic Surgery
The heart was explored through a median sternotomy. After removing a hematoma from the surface of the right ventricular (RV), a large amount of blood appeared from the laceration of RV, which was 3 cm long and ran parallel to the left anterior descending coronary artery (LAD). The RV laceration was repaired using three pairs of 4-0 Prolene sutures (Ethicon Inc., Somerville, NJ, USA) buttressed with felt pledgets, while bleeding was controlled by manual pressure. Care was taken not to injure the LAD, which was within 15 mm of the laceration. Another 15 mm long laceration was found adjacent to the postero-lateral branch of the circumflex coronary artery, when the apex was lifted to inspect the back of the heart. This laceration was in the form of a slit without active bleeding and was adjacent to the coronary artery, thus a collagen mesh dressing covered by fibrin glue (TachoComb patch; Ny-comed Austria, GmbH, Linz, Austria) was applied instead of placing sutures for hemostasis. A hole in the pericardium was found on the opposite side of the laceration in the LV. A laparotomy was then carried out to investigate the intraperitoneal bleeding. Except for the hematoma in the omentum, the abdominal organs were intact. The patient uneventfully recovered to be transferred to psychiatric facility seven days after surgery. He has been doing well for more than three years since surgery and a ventricular pseudoaneurysm and intracardiac injuries such as a post-traumatic ventricular septal defect or injury to the mitral apparatus were ruled out by echocardiography and CT-scan one month after surgery. 3. Comment In the absence of early diagnosis and management, penetrating cardiac injuries are associated with a high mortality. Patel et al. advocated the importance of echo-
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Fig. 1. Preoperative computed tomogram showing pneumopericardium and left hemothorax with extravasation of contrast medium.
cardiography in the emergency room, which had a specificity of 99.3% and sensitivity of 100% for identifying penetrating cardiac injuries w2x. We performed echocardiography in the emergency room in the present case to rule out a cardiac tamponade. The penetrating cardiac injuries in our case were identified by CT-scan which demonstrated a pneumopericardium and hemothorax. The presence of a pneumopericardium following penetrating injuries of the chest is highly suggestive of cardiac injury and is generally considered as an indication for surgery. Some unstable patients or patients in shock may benefit from cardiography in emergency room before being transferred to the operating room w3x. On the other hand, conservative treatment has also been reported successful in selected patients with penetrating cardiac injuries. Demetriades and colleagues demonstrated that surgery was necessary for only one patient among 20 patients with pneumopericardium following penetrating chest trauma and suggested that these patients could be treated conservatively, as long as they are stable and closely observed by serial echocardiography w4 x . Operative findings revealed that the knife had penetrated the heart from the RV to the posterior wall of the LV, causing a hole in the pericardium that drained blood from the ruptured heart without causing a cardiac tamponade. Hemostasis for posterior cardiac injuries is difficult and sometimes requires cardiopulmonary bypass, which may cause bleeding from other injured organs in patients with multiple traumas. For the repair of the ventricular free wall defects there are sutureless methods using tissue
adhesives such as gelatin resorcin formaldehyde (GRF) glues, fibrin glues, cyanoacrylate, and TachoComb patch. Although GRF glues have greater bonding strength than fibrin glues, the cytotoxicity of GRF has been indicated in aortic surgery w5x and Iha and colleagues also reported LV pseudoaneurysm after cardiac rupture was repaired with GRF glues w6x. Cyanoacrylate, too, has cytotoxicity w7x, though Padro and colleagues treated 13 cardiac rupture patients using cyanoacrylate with excellent results w8x. A TachoComb patch consists of collagen mesh and fibrin glues which reproduce the normal clotting cascade without cytotoxicity. The clinical efficacy of TachoComb in cardiac surgery was demonstrated in the treatment of atrioventricular disruption w9x as well as LV rupture after acute myocardial infarction. The durability of TachoComb patch in the repair of postinfarction cardiac rupture has been demonstrated by follow-up echocardiography w10x. We emphasize the usefulness of the TachoComb patch for the present case in which cardiac injury is close to the main coronary arteries in the posterior wall of the heart and cardiopulmonary bypass (CPB) is not preferable because of multiple traumas. We, however, would have to put our patient on CPB to place the sutures precisely in case of massive bleeding from LV laceration. Therefore, CPB should be always ready for use, before exploration of cardiac injury. References w1x Campbell NC, Thomson SR, Muckart DJ, Meumann CM, Van Middelkoop I, Botha JB. Review of 1198 cases of penetrating cardiac trauma. Br J Surg 1997;84:1737–1740. w2x Patel AN, Brennig C, Cotner J, Lovitt MA, Foreman ML, Wood RE, Urschel HC Jr. Successful diagnosis of penetrating cardiac injury using surgeon-performed sonography. Ann Thorac Surg 2003;76:2043–2047. w3x Karmy-Jones R, van Wijngaarden MH, Talwar MK, Lovoulos C. Cardiopulmonary bypass for resuscitation after penetrating cardiac trauma. Ann Thorac Surg 1996;61:1244–1245. w4x Demetriades D, Charalambides D, Pantanowitz D, Lakhoo M. Pneumopericardium following penetrating chest injuries. Arch Surg 1990;125: 1187–1189. w5x Yoshitatsu M, Nomura F, Katayama A, Tamura K, Katayama K, Ihara K, Nakashima Y. Pathologic findings of aortic redissection after glue repair of proximal aorta. J Thorac Cardiovasc Surg 2004;127:593–595. w6x Iha K, Ikemura R, Higa N, Akasaki M, Kuniyoshi Y, Koja K. Left ventricular pseudoaneurysm after sutureless repair of subacute left ventricular free wall rupture: a case report. Ann Thorac Cardiovasc Surg 2001; 7:311–314. w7x Kaplan M, Baysal K. In vitro toxicity test of ethyl 2-cyanoacrylate, a tissue adhesive used in cardiovascular surgery, by fibroblast cell culture method. Heart Surg Forum 2005;8:E169–E172. w8x Padro JM, Mesa JM, Silvestre J, Larrea JL, Caralps JM, Cerron F, Aris A. Subacute cardiac rupture: repair with a sutureless technique. Ann Thorac Surg 1993;55:20–24. w9x Schuetz A, Schulze C, Wildhirt SM. Off-pump epicardial tissue sealing – a novel method for atrioventricular disruption complicating mitral valve procedures. Ann Thorac Surg 2004;78:569–574. w10x Muto A, Nishibe T, Kondo Y, Sato M, Yamashita M, Ando M. Sutureless repair with TachoComb sheets for oozing type postinfarction cardiac rupture. Ann Thorac Surg 2005;79:2143–2145.
