eMedicine Specialties > Clinical Procedures > Cardiothoracic Procedures

Ventricular Repair

Author: Jennifer Kanapicki, MD,, Resident Physician, Division of Emergency Medicine, Stanford University School of Medicine
Coauthor(s): Plomarz R Irani, MD, Attending Physician, Department of Emergency Medicine, Kaiser Permanente Medical Center Santa Clara
Contributor Information and Disclosures

Updated: Nov 13, 2009

Introduction

Ventricular repair, or cardiorrhaphy, has long been one of the most dramatic and lifesaving procedures performed in the emergency department. Around 3000 BC, 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 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 emergent cardiac repair in patients who sustain life-threatening penetrating trauma to the heart.

Cardiac trauma is divided into 2 mechanisms: blunt and penetrating.

  1. Blunt injuries: Cardiac rupture following blunt thoracic trauma usually causes death at the scene and is not typically encountered clinically.4
  2. 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.5

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, this is a triangular region bordered by the midclavicular lines laterally, the clavicles superiorly, and the costal margins inferiorly.5

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.5

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.5 For more information, see eMedicine Radiology article Pneumothorax.

A true pneumothorax line. Note that the visceral ...

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

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A true pneumothorax line. Note that the visceral ...

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


The Focused Assessment with Sonography in Trauma (FAST) examination is rapidly becoming the diagnostic tool of choice in the emergency department for identifying pericardial effusions. It does have its limitations, however, as it is both operator- and patient-dependent. It should be used primarily to direct and prioritize management.6

An essential part of the management of patients in extremis from cardiac injury is thoracotomy for cardiac resuscitation, 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 eMedicine article Emergency Bedside Thoracotomy.

Multiple methods are used in the emergent management of cardiac wounds.

  • Digital pressure: This method is used for small wounds and can be used to control bleeding on the way to the operating room.
  • Foley catheter: For larger wounds, a Foley catheter can be inserted through the wound and inflated; with gentle traction, tamponade can be accomplished. Placing a Foley catheter can also stop hemorrhage so cardiorrhaphy can be performed or so a patient can be transported to the operating room for repair. An additional advantage of using the Foley catheter is the ability to administer intracardiac medications, fluids, or blood.7,8
  • Immediate cardiorrhaphy (in the emergency department): This method has been found to yield a survival rate up to 31% in patients presenting with penetrating cardiac injuries.6

Indications

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 emergent 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 emergency department9
  • Persistent hypotension or signs of cardiac tamponade in the setting of penetrating chest trauma
  • Cardiac arrest in the emergency department, in the setting of blunt trauma

Contraindications

  • Clinically stable patient
  • Blunt trauma in patients with no signs of life upon arrival10
  • Patient with evidence of prolonged death (eg, rigor mortis, livor mortis)
  • Patient whose life is unsalvageable (eg, decapitation)

More on Ventricular Repair

Overview: Ventricular Repair
Treatment & Medication: Ventricular Repair
Multimedia: Ventricular Repair
References
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References

  1. Wall MJ Jr, Mattox KL, Chen CD, Baldwin JC. Acute management of complex cardiac injuries. J Trauma. May 1997;42(5):905-12. [Medline].

  2. Rehn L. Ueber Penetrirende Herzuden und Herznaht. Arch Klin Chir. 1897;55:315.

  3. Hill LL. A report of a case of successful suturing of the heart, and a table of 37 other cases of suturing by different operations at various terminations, and the conclusions drawn. Med Rec. 1902;846.

  4. Nan YY, Lu MS, Liu KS, et al. Blunt traumatic cardiac rupture: therapeutic options and outcomes. Injury. Sep 2009;40(9):938-45. [Medline].

  5. Kang N, Hsee L, Rizoli S, Alison P. Penetrating cardiac injury: overcoming the limits set by Nature. Injury. Sep 2009;40(9):919-27. [Medline].

  6. Asensio JA, Stewart BM, Murray J, et al. Penetrating cardiac injuries. Surg Clin North Am. Aug 1996;76(4):685-724. [Medline].

  7. Moulton C, Pennycook A, Crawford R. Intracardiac therapy following emergency thoracotomy in the accident and emergency department: an experimental model. Arch Emerg Med. Jun 1992;9(2):190-5. [Medline].

  8. Wilson SM, Au FC. In extremis use of a Foley catheter in a cardiac stab wound. J Trauma. Apr 1986;26(4):400-2. [Medline].

  9. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. Practice management guidelines for emergency department thoracotomy. J Am Coll Surg. Sep 2001;193(3):303-9. [Medline].

  10. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. Mar 2000;190(3):288-98. [Medline].

  11. Boczar ME, Rivers E. Resuscitative thoracotomy. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: Saunders; 2004:336.

  12. Biffl WL, Moore EE, Johnson JL. Emergency department thoracotomy. In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma. 5th ed. New York, NY: McGraw-Hill; 2004:242-4.

  13. Jackimyczyk KC, Ordog GJ. Thoracotomy. In: Rosen, ed. Atlas of Emergency Procedures. Philadelphia, Pa: Elsevier; 2001:46-9.

  14. Ordog GJ. Cardiorrhaphy. In: Rosen P, Chan TC, Sternbach G, eds. Atlas of Emergency Procedures. Philadelphia, Pa: Elsevier; 2001:54-5.

  15. Bowman MR, King RM. Comparison of staples and sutures for cardiorrhaphy in traumatic puncture wounds of the heart. J Emerg Med. Sep-Oct 1996;14(5):615-8. [Medline].

  16. Mayrose J, Jehle DV, Moscati R, Lerner EB, Abrams BJ. Comparison of staples versus sutures in the repair of penetrating cardiac wounds. J Trauma. Mar 1999;46(3):441-3; discussion 443-4. [Medline].

  17. Macho JR, Markison RE, Schecter WP. Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination. J Trauma. May 1993;34(5):711-5; discussion 715-6. [Medline].

  18. Ivatury RR. The Injured Heart. In: Moore EE, Mattox KL, Feliciano DV, eds. Trauma. 4th ed. New York, NY: McGraw-Hill; 2000:551-5.

  19. Beck CS. Wounds of the Heart. Arch Surg. 1926;13:205.

  20. Eckstein M, Henderson S. Thoracic trauma. In: Marx, ed in chief. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2006:453.

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Further Reading

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Keywords

ventricular repair, cardiorrhaphy, thoracotomy, penetrating chest trauma, cardiac tamponade, laceration repair, cardiac repair, emergency cardiac repair, emergent ventricular repair, ED ventricular repair, blunt chest trauma

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Contributor Information and Disclosures

Author

Jennifer Kanapicki, MD,, Resident Physician, Division of Emergency Medicine, Stanford University School of Medicine
Jennifer Kanapicki, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Plomarz R Irani, MD, Attending Physician, Department of Emergency Medicine, Kaiser Permanente Medical Center Santa Clara
Plomarz R Irani, MD is a member of the following medical societies: American College of Emergency Physicians and California Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Brett C Sheridan, MD, FACS, Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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