Blunt cardiac rupture

The role and timing of cardiopulmonary bypass in the surgical repair of traumatic cardiac injury

OBJECTIVES

The management of traumatic cardiac injury (TCI) may require a prompt treatment, including the use of cardiopulmonary bypass (CPB) followed by surgical repair. This study evaluated the surgical outcomes among TCI patients.

METHODS

From August 2003, 21 patients with TCI were underwent emergent surgical repair. TCI was classified as grade I to VI according to the Cardiac Injury Organ Scale (CIS) of the American Association for Surgery of Trauma, and severity was evaluated using the Injury Severity Score (ISS).

RESULTS

Of the 21 patients, the mean age and ISS were 54.8 ± 18.8 years and 26.5 ± 6.3, respectively, including13 blunt and eight penetrating injuries. A CIS grade of IV or greater was observed in 17 patients and unstable hemodynamics in 16. CPB or extracorporeal membranous oxygenation (ECMO) were used in three patients before they underwent surgery and in seven patients after undergoing sternotomy, including three on whom a canular access route was prepared preoperatively. There was a significant correlation between the preoperative width of pericardial effusion and the use of CPB (p < 0.05). Overall hospital mortality was 14.3%, and 100% in patients with uncontrolled bleeding during surgery. All patients who underwent CPB before or during surgery, in whom a standby canular access route had been established, survived.

CONCLUSIONS

TCI is associated with a high mortality rate, and survival depends on efficient diagnosis and the rapid mobilization of the operating room. Preparations for CPB or establishing a canular access route should be made before surgical procedures in cases in which the hemodynamics are unstable.

Traumatic right ventricular rupture: Case report and brief review of the literature

Rupture of the right ventricular (RV) myocardium is associated with serious morbidity and mortality. Under very rare conditions, a tear in the ventricular wall can lead to the formation of a pseudoaneurysm: an external outpouching of the ventricle that is stabilized by the pericardium, thrombus formation, and/or adhesions. Here, we present a 75-year-old man with RV free wall rupture with pseudoaneurysm following a motor vehicle collision. With concerns for blunt cardiac trauma, initial CTA chest revealed focal outpouching and extension of contrast outside of the confines of the RV chamber, compatible with pseudoaneurysm formation. In this case, conservative management of the pseudoaneurysm was preferred over surgical management, due to the thin RV free wall and present comorbid conditions. We highlight how CTA chest offers a reliable tool for tracking the stability of pseudoaneurysms in the RV and can guide clinical management through directing treatment strategies and appropriate follow-up intervals.

Right atrial appendage rupture and cardiac tamponade secondary to blunt trauma

Background

Right atrial appendage rupture from blunt trauma is exceedingly rare, even more so when no other chest wall injuries are found. Very few cases have been documented with respect to survival from such an injury.

Purpose

To highlight the optimal management of such cases, namely through timely and safe transport to a trauma centre, maintaining a high degree of clinical suspicion for tamponade, early diagnostic ultrasound use, pericardial decompression, haemorrhage control and situational control.

Case presentation

A case report delineating the diagnostic and therapeutic approach to an individual with right atrial appendage rupture. Subsequent post-operative and convalescent course till hospital discharge.

A young male patient involved in a high-speed motor vehicle accident was hypotensive at the scene with altered sensorium. Transport to a trauma centre was delayed due to entrapment and geographical location. An ultrasound done on arrival identified cardiac tamponade, which was successfully treated with an emergent left lateral thoracotomy, pericardial decompression, and haemorrhage control from a ruptured right atrial appendage, with definitive closure in the operating theatre.

Conclusion

Whilst rare, haemodynamic compromise in the absence of obvious thoracic trauma following high-energy, rapid deceleration mechanisms should raise suspicion for right atrial appendage rupture with pericardial tamponade. Aggressive resuscitation, early diagnostic ultrasound use and urgent pericardial decompression are essential in maximising the likelihood of positive outcomes.

Isolated Right Atrial Rupture From Blunt Chest Trauma in Motor Vehicle Collisions: Mechanisms of Injury and Outcomes

ABSTRACT

Isolated right atrial rupture after nonpenetrating blunt chest trauma is rare, and very few cases have been reported in the literature. Isolated right atrial rupture is a diagnostic challenge in these patients, who are mostly victims of motor vehicle collisions. The clinical presentation is heterogeneous and can vary depending on rupture location and size. The anatomical sites mostly involved are the appendage and the free wall followed by the superior and inferior vena cava junctions. The present case study shows a fatal isolated rupture of the right atrial appendage in a victim of a motor vehicle collision. At the emergency room, a computed tomography scan revealed a severe pericardial blood effusion, and pericardiocentesis was promptly performed. Unfortunately, the patient suddenly worsened just before cardiac surgery. Autopsy findings showed a cardiac tamponade due to a linear laceration 1.8 cm in length on the right atrial appendage. No other relevant injuries were observed. A prompt diagnosis of isolated right atrial rupture can be crucial for victims of blunt chest trauma with unexplained hypotension or hemodynamic instability to improve their chances of survival. Medicolegal issues can be raised mainly related to delayed diagnosis. Once a cardiac rupture is suspected, the injury repair is essential to achieve the best outcome.

A First Report: Two Cases of Survival and Full Recovery After Blunt Cardiac Rupture Requiring Emergency Department Thoracotomy

Blunt traumatic cardiac rupture is an uncommon event in trauma and survival is rare. While multiple isolated accounts of repair of blunt cardiac rupture have been reported in the literature, there is not a single report of survival from right ventricular rupture following an emergency department thoracotomy (EDT). We report 2 cases where patients have survived such injuries and have made a full recovery. These patients are from a single institution who lost pulses on arrival to the emergency department; then underwent EDT with relief of cardiac tamponade with hemorrhage control by temporary closure, and subsequent definitive repair of right ventricular rupture in the operating room. Both were multiply injured and survived to discharge without neurologic sequelae and have made a full recovery back to their baseline function. This setting may represent an important use of EDT among blunt trauma patients, where time to survival and recovery may dependent on the speed of hemorrhage control and return of cardiac activity.

False negative of pericardial effusion using focused assessment with sonography for trauma and enhanced CT following traumatic cardiac rupture; A case report

Background

The focused assessment with sonography for trauma (FAST) examination is helpful for the identification of pericardial effusion in trauma. However, in a cardiac rupture with a pericardial perforation, pericardial effusion is not always detected by FAST. We experienced the case that FAST and enhanced CT failed to detect pericardial effusion.

Case presentation

A 51-year old woman injured after falling from a height of 3 m was brought to our institute. Focused assessment with sonography for trauma and enhanced computed tomography did not reveal any pericardial effusion; however, a massive hemothorax was revealed. Because the patient's hemodynamic state had become unstable, we performed an urgent left anterolateral thoracotomy. A left pericardial perforation was detected. By performing a clamshell thoracotomy, we found a rupture of 1 cm in diameter at the left atrial appendage. The hemodynamic state was stabilized by suturing the injury site. The postoperative course was uneventful, and the patient was transferred to another hospital after 31 days of admission.

Conclusions

Cardiac injury in the left atrial appendage is rare and sometimes difficult to diagnose and to repair. In the case of a blunt chest trauma with a massive hemothorax, although focused assessment with sonography for trauma gives negative results for pericardial effusion, a cardiac rupture with pericardial perforation should be considered.

Right Atrial Pseudoaneurysm Complicating Epithelioid Hemangioendothelioma

Cardiac pseudoaneurysm is uncommon among young adults with trauma. Infection, prior cardiac procedure, or cardiac operations are the most common reported causes. Right atrial pseudoaneurysm (RAPA) is extremely rare. Although often challenging to diagnose, advances in noninvasive imaging have improved the ability to diagnose cardiac pseudoaneurysms. We present a case of RAPA, highlighting the diagnostic accuracy of echocardiography in this rare entity.

Isolated right atrial rupture from blunt trauma: a case report with systematic review of a lethal injury

Background

Isolated right atrial rupture (IRAR) from blunt chest trauma is rare. There are no physical exam findings and non-invasive testing specific to the condition, which result in diagnostic delays and poor outcomes. We present a case of IRAR along with a systematic review of similar cases in the literature.

Case report

A 23-year-old male presented following a motor vehicle accident (MVA). He was bradycardic and hypotensive during transportation; and required intubation. There were contusions along the right chest wall with clear breath sounds, and no jugular venous distension, muffled heart sounds. Hemodynamic status progressively worsened, ultimately leading to his death. However, no external sources of bleeding or evidence of cardiac tamponade was found.

Methods

A search of PubMed, Ovid, and the Cochrane Library using: (Blunt OR Blunt trauma) AND (Laceration OR Rupture OR Tear) AND (Right Atrium OR Right Atrial). Articles were included if they were original articles describing cases of IRAR.

Results

Forty-five reports comprising seventy-five (n = 75) cases of IRAR.

Conclusion

IRAR most commonly occurs following MVAs as the result of blunt chest trauma. Rupture occurs at four distinct sites and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires a high index of suspicion, as patients’ hemodynamics can rapidly deteriorate. The presentations vary depending on multiple factors including rupture size, pericardial integrity, and concomitant injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding source. A pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are favourable with timely recognition and prompt surgical intervention.

Non-surgical management in hemodynamically unstable blunt traumatic pericardial effusion: A feasible option for treatment

INTRODUCTION

Little is known about the outcomes of deliberate non-surgical management for hemodynamically unstable patients with blunt traumatic pericardial effusion. We evaluated the efficacy of management with pericardiocentesis or subxiphoid pericardial window in hemodynamically unstable patients who reach the hospital alive with blunt traumatic pericardial effusion.

METHODS

We conducted a review of a consecutive series of patients with pericardial effusion following blunt trauma who arrived at Fukui Prefectural Hospital between January 1, 2009 and December 31, 2017. All patients with traumatic pericardial effusion were included, irrespective of the type of blunt trauma.

RESULTS

Eleven patients were identified arrived to the Emergency Department with a pericardial effusion after blunt trauma. Of the eleven patients, five patients had cardiopulmonary arrest on arrival and none survived. Of the other six patients who reached the hospital alive, five were hemodynamically unstable and clinically diagnosed with cardiac tamponade. One patient was hemodynamically stable and managed conservatively without pericardiocentesis or pericardial window. Otherwise, two patients were managed with pericardiocentesis alone. One patient was managed with pericardial window alone. One was managed with both pericardiocentesis and pericardial window. The remaining patient underwent median sternotomy because of unsuccessful pericardial drainage tube insertion. All six patients who reached the hospital alive survived. Five patients did not require surgical repair.

CONCLUSION

The results of the present study suggested that non-surgical management of hemodynamically unstable patients who reach hospital alive with blunt pericardial effusion may be a feasible option for treatment.

Blunt Traumatic Cardiac Rupture: Single-Institution Experiences over 14 Years

Background

Blunt traumatic cardiac rupture is rare. However, such cardiac ruptures carry a high mortality rate. This study reviews our experience treating blunt traumatic cardiac rupture.

Methods

This retrospective study included 21 patients who experienced blunt traumatic cardiac rupture from 1999 to 2015. Every patient underwent surgery. Several variables were compared between survivors and fatalities.

Results

Sixteen of the 21 patients survived, and 5 (24%) died. No instances of intraoperative mortality occurred. The most common cause of injury was a traffic accident (81%). The right atrium was the most common location of injury (43%). Ten of the 21 patients were suspected to have cardiac tamponade. Significant differences were found in preoperative creatine kinase–myocardial band (CK-MB) levels (p=0.042) and platelet counts (p= 0.004) between the survivors and fatalities. The patients who died had higher preoperative Glasgow Coma Scale scores (p=0.007), worse Trauma and Injury Severity Scores (p=0.007), and higher Injury Severity Scores (p=0.004) than those who survived.

Conclusion

We found that elevated CK-MB levels, a low platelet count, and multi-organ traumatic injury were prognostic factors predicting poor outcomes of blunt cardiac rupture. If a patient with blunt traumatic cardiac rupture has these factors, clinicians should be especially attentive and respond promptly in order to save the patient’s life.

Cardiac Contusion with Early Ventricular Rupture—A Case Report

Myocardial contusion is a common concomitant of high-speed deceleration injuries in our modern society. Despite increasing awareness of this entity among health care professionals, in many cases the diagnosis remains a difficult one to make because of a scarcity of physical signs. The diagnosis is, however, extremely important because of the possible complications, which include low cardiac output state, conduction defects, atrial and ventricular dysrhythmias, and, rarely, even cardiac rupture. Much less common, but also clinically impor tant, is rupture of the free cardiac wall from blunt trauma.

A case of cardiac contusion caused by blunt trauma sustained in a motor vehicle accident complicated by early ventricular rupture is presented. Ten hours after arrival at the hospital, this patient abruptly became hypotensive and sustained a cardiopulmonary arrest, which did not respond to the usual medical measures. Upon open thoracotomy the patient was found to have suffered a right ventricular rupture, which was repaired; however, the patient subse quently expired.

CPR-associated right ventricular rupture in the setting of pulmonary embolism

Cardiopulmonary resuscitation (CPR) is an inherently traumatic procedure. Successful resuscitations are often complicated by iatrogenic injuries to structures of the neck, thorax, or abdomen. Rib and sternal fractures are the most frequently induced injuries. However, rare and life-threatening trauma to vital organs such as the heart may also occur during CPR. We describe a novel case of CPR-associated right ventricular rupture in a woman with acute-on-chronic pulmonary embolism and no known pre-existing cardiac disease. We propose that chest compressions in the setting of elevated right ventricular pressure resulted in cardiac rupture, in this case.

Successful diagnosis of pericardial rupture caused by blunt chest trauma using contrast ultrasonography

A 65-year-old male developed acute myocardial infarction due to coronary artery dissection and tricuspid valve injury after blunt chest trauma. Acute myocardial infarction was treated by coronary artery intervention; however, refractory heart failure with pleural effusion remained. The first transthoracic echocardiography (TTE) on admission failed to clearly visualize the tricuspid valve and right ventricle due to poor image quality. A follow-up TTE with contrast ultrasonography revealed pericardial rupture in addition to tricuspid regurgitation. Ruptures of the tricuspid papillary muscle and pericardium were confirmed during surgery and were repaired successfully. Blunt chest trauma results in various cardiac injuries including cardiac rupture, intramural hematoma, valvular injury, coronary artery injury, and electrical disturbances, leading to critical conditions and high mortality. Of such blunt trauma-induced injuries, coronary artery dissection, tricuspid valve injury, and pericardial rupture caused by blunt chest trauma are rare, and simultaneous occurrence of the three types of injuries that were successfully repaired has not been reported. In addition, this case indicates the utility of contrast ultrasonography for diagnosis of pericardial rupture caused by blunt chest trauma.

Traumatic right atrial pseudoaneurysm

Pseudoaneurysm is defined as contained blood pooling due to rupture of vascular wall. They have higher risk of rupture and hence are usually managed aggressively. Trauma, infection and prior surgery are the most common etiologies for pseudoaneurysm of most sites. Traumatic cardiac pseudoaneurysm are rare and poses a diagnostic challenge to the treating physician since there is no specific symptoms associated with pseudoaneurysm and electrocardiogram; cardiac enzymes and echocardiogram may be unrevealing or inconclusive in many cases. Cross-sectional imaging [computed tomography (CT) and magnetic resonance imaging (MRI)] is done in cases with high index of suspicion and is the standard modality for diagnosis for cardiac pseudoaneurysm. We present a case of conservatively managed post-traumatic right atrial pseudoaneurysm with aim to highlight the role of electrocardiography (ECG)-gated multidetector computed tomography (MDCT) in diagnosis and follow-up of this rare entity that ultimately underwent rapid partial thrombosis.

Damage control surgery in blunt cardiac injury

Background: Blunt cardiac injury (BCI) is a rare, but life threatening injury. The treatment of BCI is surgical repair. However, in a BCI patient with hypothermia, acidosis, and coagulopathy, an attempt to control the bleeding completely by surgery alone may not be successful. Damage control principles should be used in this situation.

Objective: To study a BCI patient who underwent a successful operation using damage control principles.

Methods: We reviewed and analyzed the patient’s chart, operative notes and follow up visit records. Review of the literature regarding the issue was also conducted.

Results: We report the case of a patient with BCI who developed hypothermia and coagulopathy during surgery. Abbreviated surgical repair was performed with a right pleuropericardial window created to avoid blood accumulation in the pericardial sac. Subsequent aggressive resuscitation was performed in the intensive care unit. We accepted ongoing bleeding through the right chest tubes while correction of hypothermia and coagulopathy was undertaken. The bleeding was gradually stopped once the patient’s physiology was restored. Although the patient developed a retained right hemothorax requiring subsequent video-assisted thoracoscopic surgery on the third postoperative week, he recovered uneventfully and was discharged on postoperative day 36.

Conclusion: In patients with BCI who develop coagulopathy during surgery, terminating the operation quickly and creating a pleuropericardial window is a possible bailout solution because this can prevent postoperative cardiac tamponade without leaving the chest open. Continue bleeding from the chest tubes is acceptable provided that adequate resuscitation to correct coagulopathy is underway.

Coronary sinus and atrioventricular groove avulsion after motor vehicle crash

Simultaneous cardiac and pericardial rupture from blunt chest trauma is a highly lethal combination with rarely reported survival. We report of a case of young patient with a right atrioventricular groove injury, pericardial rupture and a unique description of a coronary sinus avulsion following blunt chest trauma. Rapid recognition of this injury is crucial to patient survival, but traditional diagnostic adjuncts such as ultrasound, echocardiography and computed tomography are often unhelpful. Successful repair of these injuries requires high suspicion of injury, early cardiac surgery involvement of and possible even placement of the patient on cardiopulmonary bypass.

Right massive haemothorax as the presentation of blunt cardiac rupture: the pitfall of coexisting pericardial laceration

A 74-year old female was transferred to our institution because of blunt chest trauma. Chest X-ray and computed tomography (CT) revealed right haemothorax and little pericardial effusion. She was taken to the operating theatre for emergent operation because of hypotension and massive bleeding from the right-sided chest tube. Cardiopulmonary resuscitation was started during surgical exploration. There were three 1-cm lacerations actively bleeding from the right atrium and inferior vena cava junction, which were repaired successfully. Furthermore, we identified a 10 cm laceration in the right-side pleuropericardium and a communication existing between the pericardial space and the right pleural space.

Rupture of the left atrial roof due to blunt trauma

Cardiac rupture after blunt trauma is rare and associated with high mortality. The anatomic pattern of blunt cardiac rupture has been demonstrated with the right cardiac chambers more frequently affected than the left. Furthermore, left atrial injury is usually restricted to the atrial appendage and the pulmonary vein-atrial junction. Herein, we report the first case of a 61-year old man with a rupture of the left atrial roof after blunt trauma with minimal thoracic injury.

Pectus excavatum in blunt chest trauma: a case report

Introduction

Blunt cardiac rupture is an exceedingly rare injury.

Case presentation

We report a case of blunt cardiac trauma in a 43-year-old Caucasian German mother with pectus excavatum who presented after a car accident in which she had been sitting in the front seat holding her two-year-old boy in her arms. The mother was awake and alert during the initial two hours after the accident but then proceeded to hemodynamically collapse. The child did not sustain any severe injuries. Intraoperatively, a combined one-cm laceration of the left atrium and right ventricle was found.

Conclusion

Patients with pectus excavatum have an increased risk for cardiac rupture after blunt chest trauma because of compression between the sternum and spine. Therefore, patients with pectus excavatum and blunt chest trauma should be admitted to a Level I Trauma Center with a high degree of suspicion.

Nonoperative management of blunt traumatic cardiac rupture: considerations of a novel approach

Blunt traumatic cardiac rupture carries a dismal prognosis. Patients who survive to presentation are treated with prompt surgical repair. Operative intervention carries significant morbidity and mortality, as these patients present in extremis. Intervention can be complicated by prior cardiac surgery. Obliteration of the pericardial space from adhesions may offer the patient an alternative conservative option under rare circumstances. We present a case of an older man with blunt cardiac rupture caused by a motor vehicle crash. The patient remained hemodynamically stable as his rupture only communicated with a small space within his obliterated pericardial sac. He was managed nonoperatively.

Isolated right atrial tear following blunt trauma

Cardiac chamber rupture in blunt trauma is uncommon and is associated with a high mortality rate. We report a patient involved in a motor vehicle collision with an isolated right atrial injury resulting in a pericardial effusion associated with hemodynamic compromise. A 20 year-old intoxicated female was transported after sustaining a collision in her vehicle. The patient remained mildly hypotensive and tachycardic despite volume resuscitation. FAST was negative showing good cardiac motion and no fluid in her abdomen. A CT scan revealed a mediastinal hematoma and free intra-abdominal fluid, and trans-thoracic echocardiogram (TTE) identified a mass within the right atrium associated with a pericardial effusion. In the operating room, clot was removed from within the pericardium. Hypothermic circulatory arrest and cardiopulmonary bypass were performed and a single laceration involving the right atrium was repaired after removing a large intra-atrial clot. A negative concurrent exploratory laparotomy was performed. The patient was discharged from the hospital postoperative day 6. This report presents an isolated right atrial tear associated with pericardial tamponade following blunt trauma and we discuss the role of early diagnosis and treatment.

Cardiac rupture following blunt trauma

Cardiac rupture is the most extreme manifestation of blunt cardiac injury. In the first half of the 20th century this lesion was uniformly fatal. Since the first successful post-traumatic cardiorrhaphy by Desforges in 1955, multiple case reports and retrospective reviews have documented successful operative repair and survival of patients with this injury. Despite these successes, blunt cardiac rupture remains associated with a high mortality rate. The rarity of this condition and the heterogeneity of the literature make determination of exact epidemiologic data difficult. The classic clinical presentation is not universal and a subset of patients may present asymptomatically. Rapid transportation to medical care, accurate timely diagnosis and emergent operative intervention are essential for successful outcome. The use of ultrasonography in the trauma bay is a key component of early identification of these injuries. Specific outcome factors associated with survival are difficult to determine and even in those who survive to medical attention mortality rates remain as high as 60—90%.

Blunt cardiac trauma: lessons learned from the medical examiner

OBJECTIVE

The objective of this study was to analyze autopsy findings after blunt traumatic deaths to identify the incidence of cardiac injuries and describe the patterns of associated injuries.

METHODS

All autopsies performed by the Los Angeles County Forensic Medicine Division for blunt traumatic deaths in 2005 were retrospectively reviewed. Only cases that underwent a full autopsy including internal examination were included in the analysis. The study population was divided into two groups according to the presence or absence of a cardiac injury and compared for differences in baseline characteristics and types of associated injuries.

RESULTS

Of the 881 fatal victims of blunt trauma received by the Los Angeles County Forensic Medicine Division, 304 (35%) underwent a full autopsy with internal examination and were included in the analysis. The mean age was 43 years +/- 21 years, patients were more often men (71%) and were intoxicated in 39% of the cases. The most common mechanism was motor vehicle collision (50%), followed by pedestrian struck by auto (37%), and 32% had a cardiac injury. Death at the scene was significantly more common in patients with a cardiac injury (78% vs. 65%, p = 0.02). The right chambers were the most frequently injured (30%, right atrium; 27%, right ventricle). Among the 96 patients with cardiac injuries, 64% had transmural rupture. Multiple chambers were ruptured in 26%, the right atrium in 25%, and the right ventricle in 20% of these patients. Patients with cardiac injuries were significantly more likely to have other associated injuries: thoracic aorta (47% vs. 27%, p = 0.001), hemothorax (81% vs. 59%, p < 0.001), rib fractures (91% vs. 71%, p < 0.001), sternum fracture (32% vs. 13%, p < 0.001), and intra-abdominal injury (77% vs. 48%, p < 0.001) compared with patients without cardiac injury. Of the 96 patients with a cardiac injury, 78% died at the scene of the crash and 22% died en route or at the hospital.

CONCLUSION

Cardiac injury is a common autopsy finding after blunt traumatic fatalities, with the majority of deaths occurring at the scene. Patients with cardiac injuries are at significantly increased risk for associated thoracic and intra-abdominal injuries.

Transdiaphragmatic repositioning of the heart in the setting of emergency laparotomy after blunt trauma

Cardiac luxation after blunt trauma is a rare condition that carries a high mortality rate. We report a case of a left pericardial rupture with partial dislocation of the heart into the left pleural cavity and cardiac strangulation in a polytraumatized patient after a severe motor vehicle accident. This case is of special interest because the patient not only had cardiovascular compromise but was also actually in cardiac arrest and being resuscitated when an emergency repositioning of the heart through the diaphragm in the setting of damage control laparotomy restored circulation. This report stresses the need for a high index of suspicion for accurate early diagnosis of pericardial rupture.

Blunt traumatic cardiac rupture: therapeutic options and outcomes

INTRODUCTION

Cardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same.

METHODS

This is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome.

RESULTS

The study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18+/-5.7 (range: 25-43), 6.267+/-1.684 (range: 2.628-7.841), and 72.4+/-25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n=4), right atrial auricle (n=1), right ventricle (n=4), left ventricular contusion (n=1), and diffuse endomyocardial dissection over the right and left ventricles (n=1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state.

CONCLUSIONS

We proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.

Surgical management and treatment of a traumatic right atrial rupture

We have treated three patients with blunt traumatic right atrial rupture, all of whom survived after an emergent cardiac repair without cardiopulmonary bypass. Cardiac tamponade was seen in two of the three cases on ultrasonographic cardiography (UCG). The site of rupture was the right atrial appendage in two cases and the superior vena cava-right atrial (SVC-RA) junction in one case. Hemostasis had been obtained at the time of pericardiotomy because of compression by hematoma. Some patients with a right atrial rupture respond to initial volume resuscitation. Suspecting some cardiac injuries in patients with traumatic pericardial effusion on UCG, a patient with a right atrial rupture can survive with a high probability, without the use of cardiopulmonary bypass.

Survival following resuscitative thoracotomy for combined left ventricle and left atrium ruptures secondary to blunt trauma

Improvements in pre-hospital care and the development of integrated Trauma Systems have streamlined access for the severely injured to sophisticated, specialist Trauma Centre reception and resuscitation. We describe the initial care of a survivor of combined ruptures of the left ventricle and left atrium secondary to blunt injury. This case emphasises the contribution of such a Trauma System in achieving a favourable outcome for a severely injured trauma patient with injuries previously considered non-survivable.

Isolated right atrial appendage (RAA) rupture in blunt trauma--a case report and an anatomic study comparing RAA and right atrium (RA) wall thickness

Background

Heart chambers rupture in blunt trauma is uncommon and is associated with a high mortality. The determinant factors, and the incidence of isolated heart chambers rupture remains undetermined. Isolated rupture of the right atrium appendage (RAA) is very rare, with 8 cases reported in the reviewed literature. The thin wall of the RAA has been presumed to render this chamber more prone to rupture in blunt trauma.

Objective

To report a case of isolated RAA rupture in blunt trauma, and to compare right atrium (RA) and RAA wall thickness in a necropsy study.

Methods

The thickness of RA and RAA wall of hearts from cadavers of fatal penetrating head trauma victims was measured. Our case of isolated RAA rupture is presented. The main findings of the 8 cases reported in the literature, and the findings of our case, were organized in a table.

Result

The comparison of the data showed that wall thickness of the RAA (0.53 ± 0.33 mm) was significantly thinner than that of RA (1.11 ± 0.42 mm) (p < 0.05).

Comments

In all these 9 cases of isolated RAA rupture, cardiac tamponade occurred, RAA rupture was diagnosed intraoperatively and sutured, and the patients survived. Main mechanisms hypothesized for heart chamber rupture include mechanical compression coincident with phases of cardiac cycle, leading to high hydrostatic pressure inside the chamber. Published series include numerous cases of RA rupture, and only a few cases of RAA rupture.

Conclusion

Thus, our data suggests that wall thickness is not a determinant factor for RA or RAA rupture in blunt trauma.

An Autopsy Case of Heart Rupture From a Scooter Accident With 3 Riders

A 15-year-old male died of cardiac rupture due to blunt chest trauma from a traffic accident involving a low-speed scooter carrying 3 people and a head-on collision with a tree. The victim was sitting on the footrest of the scooter. It was concluded that the victim was compressed between the handlebar of the scooter and the other 2 passengers, causing cardiac ruptures via bidirectional compression and intravascular hydrostatic pressure. The victim may have served as a cushion for the other 2 passengers, who were not thrown from the scooter and sustained only minor injuries.

Definitive management of acute cardiac tamponade secondary to blunt trauma

Blunt cardiac injuries are a leading cause of fatalities following motor-vehicle accidents. Injury to the heart is involved in 20% of road traffic deaths. Structural cardiac injuries (i.e. chamber rupture or perforation) carry a high mortality rate and patients rarely survive long enough to reach hospital. Chamber rupture is present at autopsy in 36-65% of death from blunt cardiac trauma, whereas in clinical series it is present in 0.3-0.9% of cases and is an uncommon clinical finding. Patients with large ruptures or perforations usually die at the scene or in transit--the rupture of a cardiac cavity, coronary artery or intrapericardial portion of a major vein or artery is usually instantly fatal because of acute tamponade. The small, rare, remaining group of patients who survive to hospital presentation usually have tears in a cavity under low pressure and prompt diagnosis and surgery can now lead to a survival rate of 70-80% in experienced trauma centres. As regional trauma systems evolve, patients with severe, but potentially survivable cardiac injury are surviving to ED. Two distinct syndromes are apparent--haemorrhagic shock and cardiac tamponade. Any patient with severe chest trauma, hypotension disproportionate to estimated loss of blood or with an inadequate response to fluid administration should be suspected of having a cardiac cause of shock. For patients with severe hypotension or in extremis, the treatment of choice is resuscitative thoracotomy with pericardotomy. Closed chest cardiopulmonary resuscitation is ineffective in these circumstances. Blunt traumatic cardiac injury presenting with shock is associated with a poor prognosis. The majority of survivors of blunt or penetrating cardiac injury present to the ED/trauma centre with vital signs. The main pathophysiologic determinant for most survivors is acute pericardial tamponade. The presence of normal clinical signs or normal ECG studies does not exclude tamponade. In recent years the widespread availability and use of ultrasound for the initial assessment of severely injured patients has facilitated the early diagnosis of cardiac tamponade and associated cardiac injuries. Two cases of survival from blunt traumatic cardiac trauma are described in the present paper to demonstrate survivability in the context of rapid assessment and intervention.

[Right atrial rupture following a hoof kick to the chest wall]

Several myocardial lesions can be induced by thoracic blunt trauma. It varies from myocardial lesions to heart rupture. We report a case of right atrial rupture due to unusual blunt trauma: a hoof kick. We describe a successful management of this case. We suggest that a diagnosis of cardiac chamber rupture should be considered in all cases of blunt thoracic trauma.

Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: results of a prospective study

BACKGROUND

The clinical significance of myocardial contusion (MC) following blunt thoracic trauma is still unknown. Accordingly, in this prospective study in a regional trauma center we investigated the acute and long-term clinical significance of MC.

METHODS

One-hundred eighteen patients with manifest or suspected blunt thoracic trauma were evaluated for cardiac injury. Initial assessment was based on results of electrocardiographic, echocardiographic, and serial enzyme measurements. A follow-up (FU) assessment conducted at 3 and 12 months, respectively, was performed using electrocardiography, echocardiography, and a bicycle ergometry exercise test.

RESULTS

Of the 118 patients in the total sample, 67 (56.8%) required admission to the surgical intensive care unit (SICU) because of the severity of their noncardiac injuries. Fourteen patients of the total sample (11.8%) were diagnosed with MC and 13 of these (92.9%) belonged to the intensive care admissions, thus representing an incidence of 19.4% in this patient group. During the hospitalization period none of the patients with MC experienced acute cardiac complications. Eighty-six patients (72.0%) were assessed at FU. No new pathologies were found except in one patient. Exercise testing revealed no ECG abnormalities and none of the patients experienced limitations on the bicycle ergometer due to a cardiac cause.

CONCLUSIONS

The incidence of 19.7% of MC in our patients with blunt chest injury requiring intensive care treatment indicates that this condition is frequent in polytraumatized patients. Outcome and prognosis in patients with MC is favorable and, thus, routine cardiac work-up is not indicated. Specific diagnostic and therapeutic measures should be limited to cases where cardiac complications develop.

Isolated right atrial tear following blunt chest trauma: report of three cases

Blunt chest trauma causing isolated right atrial tear and cardiac tamponade in three patients is reported. All three patients presented with hypotension, elevated central venous pressure and altered consciousness. Echocardiographic examination demonstrated pericardial effusion in all three cases. All three patients underwent operation with a median sternotomy approach without using cardiopulmonary bypass. At operation, two patients had one tear in the right atrium, the other had two tears in the right atrium. All three patients recovered uneventfully. Early use of echocardiography to detect the presence of hemopericardium and cardiac tamponade in patients with suspected atrial rupture following blunt chest trauma is advocated.