eMedicine Specialties > Clinical Procedures > Cardiothoracic Procedures

Ventricular Repair

Jennifer Kanapicki, MD,, Resident Physician, Division of Emergency Medicine, Stanford University School of Medicine
Plomarz R Irani, MD, Attending Physician, Department of Emergency Medicine, Kaiser Permanente Medical Center Santa Clara

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 pleural line is observed clearly, with the absence of vascular marking beyond the pleural line.

• 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 department^{[9 ]}
• 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 arrival^{[10 ]}
• Patient with evidence of prolonged death (eg, rigor mortis, livor mortis)
• Patient whose life is unsalvageable (eg, decapitation)

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.

Equipment

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 Prolene (2-0) suture on a curved needle
• Teflon pledgets
• Suture scissors
• Surgical stapler
• Sterile towels
• Sponges
• Foley catheter
• Chest tube
• Towel clips

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 (Betadine) solution and sterile towels. Note, however, that preprocedural antiseptic skin preparation may be ineffective and may delay the procedure.^{[11 ]}

Technique

Thoracotomy

• 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 need 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.
• 
  

  

  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.
  
  

  

  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.
• 
  

  

  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.
• 
  

  

  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.
• 
  

  

  Locate the laceration.

  
  
• Once a laceration is found, simple use of a monofilament suture (eg, 2-0 Prolene) can be used to place continuous or interrupted sutures.^{[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.^{[1 ]}To begin the cardiorrhaphy procedure with pledgets, thread nylon suture through the Teflon pledget, and place a horizontal mattress suture across the laceration.
• 
  

  

  Suture threading.

  
  
• Thread the suture through another Teflon pledget on the opposite wound edge, and complete the mattress stitch.
• 
  

  

  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, as a suture placed into or over the arteries can have disastrous consequences.^{[12,13,14 ]}
• 
  

  

  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.^{[15,16 ]}This method also reduces the risk of exposure to contaminated needles in the setting of an emergency department thoracotomy. These findings have been demonstrated in the clinical setting as well.^{[17 ]}

Pearls

• Penetrating trauma to the chest in an unstable patient is an indication for thoracotomy 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.

Complications

• Injury to underlying thoracic structures, including the lung, heart, great vessels, coronary arteries, thoracic duct, esophagus, and phrenic nerve
• Uncontrolled hemorrhage^{[14 ]}
• Postpericardiectomy syndrome (evidenced by fever, chest pain, pericardial effusion, pericardial rub, and elevated ST segments on an ECG)^{[18 ]}
• Dysrhythmias
• Physician and ancillary staff exposure to infectious blood and tissue (eg, HIV, hepatitis B, hepatitis C)^{[11 ]}
• Serious infection in the setting of emergency department thoracotomy (uncommon)^{[11 ]}

Multimedia

Media file 1: Primary incision in the fourth or fifth intercostal space.

Media file 2: Open the pleura with scissors.

Media file 3: Chest opened with rib spreader.

Media file 4: Initial opening of the pericardium with the scalpel.

Media file 5: Locate the laceration.

Media file 6: Suture threading.

Media file 7: Completed mattress stitch.

Media file 8: Sufficiently approximated laceration.

Media file 9: A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the pleural line.

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. 4^th 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. 5^th 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. 4^th 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. 6^th ed. Philadelphia, Pa: Mosby Elsevier; 2006:453.

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

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.

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Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
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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
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