Definitive Repair of a Stab Wound to the Right Ventricle With Skin Staples in Emergency

Case Report.

A 19-year-old man was brought by Emergency Medical Services to a Level I trauma center 20 minutes after sustaining 3 stab wounds to the left chest. The patient was awake and oriented, but complaining of difficulty in breathing and left sided chest pain. The patient’s vital signs were as follows: heart rate = 110 bpm, blood pressure (BP) = 110/75 mmHg, oxygen saturation = 92% on 10 L/min O₂ by facemask. The physical exam revealed 2 stab wounds in the left chest between the anterior and posterior axillary lines at the third and fourth intercostal spaces, respectively, and 1 stab wound in the left anterior cardiac box lateral to the sternum. Breathing sounds and heart sounds were normal and the neck veins did not appear to be distended. An electrocardiogram was normal. The plain chest radiograph showed a left-sided hemothorax for which a chest tube was placed and drained 200-cc of blood. A FAST (Focused Assessment with Sonography for Trauma) was positive for pericardial fluid and negative for abdominal fluid. The patient was resuscitated and prepared for transportation to the operating room (OR) for sternotomy.      As the patient was being prepared for transport, the patient became profoundly hypotensive (BP = 65/40). The patient continued to deteriorate to near arrest. The patient was intubated in the trauma bay and a resuscitative left anterolateral thoracotomy was performed. The pericardium was tense and a pericardiotomy returned a large amount of clots. Further inspection revealed a 4-cm, full-thickness laceration of the anterior wall of the right ventricle (Figure 1). Digital control of bleeding was attempted immediately. The incision was extended across the sternum into a clamshell incision to improve exposure. A Foley catheter was inserted into the wound with partial balloon inflation and minimal traction. This was followed by closure of the wound using skin staples and gentle removal of the catheter (Figure 2). At this time the patient arrested and immediately received internal cardiac massage and 1 mg of intravenous epinephrine. This returned him to a perfusing rhythm and his cardiac output returned. The patient was moved to the OR with a BP of 135/70 mmHg. No other injuries were found. Bleeding from the heart wound was noted and controlled only with the staples in situ. The patient continued to have a normal rhythm. However, he was pressor-dependent, profoundly acidotic, and hypothermic (pH = 6.9, core temperature = 34˚C). The authors elected to close the chest and move the patient to trauma intensive care unit (TICU) for further resuscitation.      The postoperative transesophageal echo revealed a 1.3-cm ventricular septal defect with 68% ejection fraction and a 1.2% shunt. The cardiology team suggested nonoperative management with consideration of balloon tamponade for repair of the defect on an outpatient basis. The patient was extubated on postoperative day 3 and discharged home on the 13th postoperative day. At the time of discharge, the patient was asymptomatic from a cardio-respiratory perspective. Two months later, the patient reported he was able to play basketball and run up 2 flights of stairs with no shortness of breath or chest pain.      

Discussion:

Control of hemorrhage in penetrating cardiac trauma is essential. Immediate control can be achieved most easily by direct finger pressure. For large wounds, a Foley catheter or Satinsky clamp may be used.^1–4 Techniques for definitive repair of cardiac wounds include sutures isolated or combined with Teflon pledgets, particularly in large wounds. Placement of sutures can be challenging and time consuming in the beating heart. The use of staples has been reported to be a safe and quick method to achieve temporary control of hemorrhage from penetrating cardiac wounds;^4,5 however, their use as a definitive measure in place of the more traditional interrupted pledgetted suture repair has not been described. In this case, the authors decided to abandon a pledgetted suture repair, as the patient was too unstable to withstand further operative intervention. The absence of tissue loss at the site of the injury coupled with the relatively low pressures on the right side of the heart certainly contributed to success in this case.      The longevity of stapled cardiorrhaphy in humans remain undetermined; however, in a swine model, the tensile strength of repaired cardiac wounds was similar in sutured and stabled injuries when tested for the same chamber.⁴ The technique of stapled cardiorrhaphy should remain in the surgeon’s armamentarium for management of penetrating cardiac injuries.      

Conclusion:

This case presented a patient with a cardiac stab wound who underwent definitive repair of the wound with staples. Although this is not the preferred method of repair for a traumatic wound to the heart, it may be used when other more traditional methods are not available to the surgeon.