196 Part V / Valvular Heart Disease
Traumatic injury to the heart can be classified according to the mechanism of injury,
penetrating or blunt trauma. The incidence of both has increased in recent decades,
continued crime and violence and rapid emergency medical transport systems have
contributed to the increase in patients with penetrating cardiac injury who reach the
hospital, whereas high-speed motor vehicle accidents have contributed to the increas-
ing frequency of blunt trauma. Each has a different clinical presentation and may
require dramatically different operative approaches; thus, each will be discussed sepa-
rately. In addition, each injury associated with blunt cardiac trauma will be reviewed
separately because most also involve additional medical personnel (general surgery,
orthopedic surgery, neurosurgery, etc.) and require thoughtful planning of intervention.
Penetrating Cardiac Injury
The mechanism of a penetrating cardiac injury dictates the location of affected heart
chambers. It is not surprising that the right ventricle, secondary to its anterior position,
is the most commonly involved cardiac chamber. In a collective review of 1802
patients, Karrell et al. identified right ventricular injury in 43%, left ventricular injury
in 33%, and atrial injury in 21% collectively (1). The remainder had had injury to the
great vessels. In another review of 109 patients, Attar et al. identified right ventricular
injury in 47%, left ventricular in 28%, and atrial in 14% of patients (2). Fully 12% of
patients had mutliple chambers injured.
Penetrating injury to the heart will typically present in one of two manners; tampon-
ade or hemorrhage. In stab wounds, pericardial tamponade predominates, with 80–90%
of cases in most series presenting with signs of tamponade (1,3,4). The prevailing opin-
ion is that adjacent pericardial fat and clot formation seal the pericardial tear, localizing
the extent of hemorrhage. However, this is dependent on the location of injury. Deme-
triades and Vander Veen noted that whereas 93% of right ventricular wounds presented
with tamponade, only 43% of left ventricular wounds presented in a like fashion (5). In
contrast, gunshot wounds will present with tamponade in only 20% (6,7), with the pre-
dominant hemorrhage varying from clinically overt to clinically ambiguous.
The importance of presentation is underscored by the rapidity at which surgery must
be performed. As in all traumatized patients, the Advanced Trauma Life Support Man-
agement Protocols formulated by the American College of Surgeons should be insti-
tuted (8). Rapid deterioration of a patient with initial signs of life may mandate an
emergency room thoracotomy, performed most expeditiously through a left anterolat-
eral approach. The intercostal space (usually fourth) is opened sharply, a thoracotomy
retractor is inserted, and the lung is retracted laterally. A longitudinal incision in the
pericardium preserves the phrenic nerve posteriorly. Direct finger pressure may allow
transport to the operative suite or, at times, direct suture repair of the cardiac wound is
required in the emergency room. If injuries to the right atrium or posterior mediastinum
are identified, the incision can be extended across the sternum. It is our practice to
clamp the aorta to facilitate volume resuscitation and improve blood flow to the coro-
nary and cerebral circulations.
The diagnosis of cardiac injury should be suspected in any patient with penetrating
injury to the chest, neck, back, or abdomen. Injuries to the precordium, epigastrium, or
superior mediastinum are in the “danger zone” and are most likely to involve the heart
(2,9). When vital signs are stable, transthoracic echocardiography has been used with
increasing frequency to aid in the diagnosis of injury to the heart (10–13). Although
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