Penetrating or blunt cardiac injury can occur at chamber-free walls, the atrial septum, or the ventricular septum and may be lethal if not recognized promptly. In blunt injury, the more commonly injured right atrium becomes torn at its confluence with the inferior vena cava, whereas the left atrium becomes torn at its confluence with the pulmonary veins. ^, Theoretically, atrial injuries are more likely in late systole because they are near maximal dimension. Conversely, ventricular injuries are theoretically more likely at maximal dimension during end diastole. Ventricular injuries do not appear to have a predictable location of injury in blunt trauma. Free wall injuries to the atria or right ventricle appear less lethal in comparison to left ventricular free wall rupture, partially in part because the lower pressures allow for hemopericardium to tamponade and thrombose rupture sites, although resultant pseudoaneurysms may also be at risk for late rupture. ^{, , ,} Left ventricular free wall rupture is often not survivable. Of those who survive the trip to a hospital, there is a broad spectrum of vague cardiac symptoms, including chest pain, dyspnea, jugular venous distension, widened cardiac silhouette, hemothorax, or pulmonary edema on chest radiograph. ^, VSDs generally occur due to blunt mechanisms; although hemodynamics stay compensated with small defects, large septal ruptures may present with pulmonary hypertension and acute heart failure.

Coronary artery injuries may complicate blunt and penetrating cardiac injury and occur in 2% to 3% of lethal blunt cardiac trauma. ^{, ,} Mechanisms of injury are similar to those of blunt and penetrating cardiac injury. The most injured coronary arteries are the left anterior descending and left main coronary arteries (76%), the LAD (presumably because of its anterior position), followed by the right coronary artery (12%), and the left circumflex. The natural history of these injuries includes myocardial infarction, cardiac tamponade, and exsanguination if not promptly addressed. Infarction is likely to include the anterior left ventricle, ventricular septum, or apex. Patients with previous blunt cardiac trauma may also present with coronary artery disease later in life, potentially related to cardiac injury.

Coronary artery injury may be suspected based on the presenting electrocardiogram. In patients with hemodynamic instability and cardiac tamponade, there is little role for delaying definitive care for the purpose of performing further time-consuming diagnostics. However, in the setting of relative hemodynamic stability and no serious concurrent injuries, additional investigations may be considered. Selective coronary angiography is the current gold standard for assessing coronary artery disease, dissection, aneurysm, or rupture. Computed tomography (CT) angiography may also be used to assess coronary injury and may save time for a patient who is already going to the CT scanner. Doppler echocardiography has also been used to diagnose coronary artery rupture. Both cardiac catheterization and echocardiography can also assess myocardial regional wall motion abnormalities, which, in conjunction with electrocardiogram (ECG) changes, may support the diagnosis of coronary artery injury. ECG findings in coronary artery injury include ST segment changes and ventricular arrhythmias. Laboratory investigations for cardiac enzymes may provide additional support for the diagnosis of coronary injury, although specificity is poor, given that troponin elevation is expected in any form of cardiac injury. ^,

Valvular injuries are another rare consequence of cardiac trauma; the mitral valve (1.25% of all blunt cardiac injuries), aortic valve (0.93%), tricuspid valve (0.13%), and pulmonic valve (0.02%) may all be injured. The higher frequency of mitral and aortic valvular injury may be a consequence of higher left-sided pressures. Injuries to cardiac valves often occur in conjunction with other cardiac injuries, confounding their clinical presentations, ^, and acute dyspnea, pulmonary edema, widened pulse pressure, elevated jugular venous pressure, and a new murmur may all support the diagnosis of valvular injury. Valvular injuries are best assessed with one or both transthoracic and transesophageal echocardiography.

Mitral valve injuries may involve the anulus, leaflets, or subvalvular apparatus, ^, and appear more frequently with blunt versus penetrating trauma, although the latter has been reported. Severity of injury ranges from rupture of small chordae tendineae to complete rupture of papillary muscles and leaflet destruction: 60% of cases involved papillary muscle disruption, 17% involved chordae tendineae injury, 13% involved leaflet injury, and 10% were mixed injuries. Patients with minor injuries and mild to moderate mitral regurgitation may be medically managed with standard heart failure therapy, with plans for eventual semielective surgical repair as needed; however, those who present with severe mitral valve injuries and acute decompensated heart failure require an immediate operation. Surgical options are largely determined by the degree of native valve destruction and concomitant cardiac injuries, with repair being attempted in some cases using well-established techniques, including anuloplasty, leaflet resection, and implantation of neochordae. ^{, ,} In a review of case reports, 57% of patients received mitral valve replacement versus 43% who underwent repair.

Aortic valve injuries may involve the anulus or cusps, and concomitant aortic injury may lead to aortic insufficiency. ^{, ,} Avulsion of the noncoronary cusp from the anulus is the most common injury pattern. Most patients with severe injuries present with acute heart failure. Operative management typically entails aortic valve replacement in most patients, but repair has been successfully performed. A high index of suspicion should be maintained for adjacent injuries, such as those to the coronary ostia, aortic root, ascending aorta, and other cardiac valves.

Similarly, tricuspid valve injury may involve leaflet, anulus, or subvalvular apparatus. ^{, ,} Indeed, 42% of cases involved chordal rupture, 27% involved papillary muscle rupture, and 15% involved leaflet injury in one report, and anular dilation was common among those with significantly delayed surgery. Many tricuspid valve injuries may be treated conservatively as tricuspid regurgitation is relatively well-tolerated, although many tricuspid injuries occur in the context of other cardiac injuries necessitating surgical repair. ^{, ,} Operative management of tricuspid regurgitation includes valve repair in most cases, although valve replacement is necessary when valve destruction is excessive. Cardiac electrical activity should be closely monitored in these patients, given the close proximity of the conduction system to the tricuspid valve, and pacemaker placement may be necessary, either perioperatively or even late after repair or replacement.

Injuries to the pulmonic valve are exceedingly rare; management has consisted of valve replacement.

Pericardial injuries may result from blunt and penetrating cardiac trauma, with approximately 36% of lethal cardiac injuries having pericardial tears. In penetrating trauma, large pericardial injuries may lead to rapid exsanguination if there is concomitant cardiac chamber injury, whereas a lesser injured or intact pericardium may allow patients to survive long enough to reach a hospital, although cardiac tamponade will likely ensue. Whereas pericardial contusion in the context of myocardial contusion may be clinically silent, more severe cases of pericardial injury may result in lethal cardiac herniation. Approximately 50% of pericardial ruptures occur at the left pleuropericardium, followed by the diaphragmatic pericardium, right pleuropericardium, and superior pericardium.

Diaphragmatic pericardial rupture may precipitate upward herniation of abdominal contents into the thorax, whereas cardiac herniation occurs after left pleuropericardial rupture. ^{, ,} Cardiac herniation is a serious complication that may lead to obstruction of inflow and outflow vessels and, thus, severely impair cardiac output. It may be suspected in the context of positional, sudden hypotension or pulselessness, abnormally located heart sounds or palpable cardiac impulses, left-shifted electrical axis on ECG, and resolution of findings with positional change. ^{, , ,}

Although minor pericardial injuries do not generally require repair, evidence of cardiac herniation is often an indication for urgent surgical repair. Closure of the pericardial defect can be achieved primarily or with augmentation using a patch graft. Late complications of traumatic pericardial injury include constrictive pericarditis, which has been reported in multiple cases.

Acute traumatic aortic disruption is covered in Chapter 24 .

The ECG is the standard screening tool for nonobvious blunt cardiac injury, and a negative result has a 98% negative predictive value for significant cardiac injury. The frequency of arrhythmias after cardiac injury is difficult to determine given the transient nature of many electrical disturbances, but it is reported that arrhythmias represent the most common complication of cardiac injuries, with up to 77% incidence. Sinus tachycardia is the most common ECG abnormality in trauma patients, largely due to a combination of pain, catecholamine surge, metabolic derangement, and hypovolemia. ^{, ,} Other than sinus tachycardia, ECG abnormalities present in 1% to 6% of thoracic trauma patients, with atrial fibrillation (AF) being most common (4% of initial ECGs); ^, however, the rate of AF after other forms of major trauma was also around 4%, and studies did not control for preexisting AF. Paroxysmal supraventricular tachycardia is a rarer atrial dysrhythmia that has been reported following blunt cardiac trauma. ^, In general, treatment for atrial arrhythmias following cardiac trauma includes rate control with beta-blockade for stable patients and cardioversion for unstable patients, as per advanced cardiovascular life support (ACLS) algorithms. Overall, about one-quarter of patients need medical management of arrhythmias.

Conduction disturbances have also been reported after blunt cardiac injury, and right bundle branch block (RBBB) appears to be the most reported. Complete atrioventricular nodal block is a rare complication but has also been reported; these cases generally require permanent pacemaker insertion. ^, Other than pacemaker insertion, treatment should be conservative.

Ventricular arrhythmias are less common and more lethal. Because many patients die prior to arriving at the hospital, the exact incidence of ventricular arrhythmia remains unknown. Prompt treatment of sustained ventricular arrhythmias should follow ACLS algorithms, and a thorough evaluation of etiology should be undertaken to determine the role of urgent intervention. ^{, ,}

Commotio cordis (CC) refers to sudden cardiac death (SCD) due to ventricular fibrillation triggered by relatively low-energy blunt trauma to the thorax, which causes abnormalities in ventricular repolarization in the absence of structural damage to the heart. ^{, ,} The understanding of CC has been supplemented by a registry, which reported that CC is the third most common cause of SCD in young athletes. Approximately 75% of all CC is attributable to direct blows to the chest during sports (predominantly baseball, ice hockey, football, and lacrosse), whereas 25% of cases occur due to other mechanisms, such as animal kicks. Approximately two-thirds of athletes with CC were aged 10 to 25 years, and 26% were younger than 10 years old. The highest likelihood of inducing fibrillation appears to be at high left ventricular pressure, with long QRS duration and QTc variability. The cardiac arrest associated with CC appears more refractory to cardiopulmonary resuscitation (CPR) and defibrillation compared to ischemic or hypoxic cardiac arrests, even when initiated early. ^, Nevertheless, rates of successful resuscitation and overall survival have increased, presumably due to availability and awareness of automatic external defibrillators. Although chest protection has been proposed as a means of further prevention, one study found that nearly 40% of CC patients were wearing chest protection.

Due to the penetrating and high-energy mechanisms involved, patients with cardiac injuries often sustain damage to other organ systems. Indeed, up to 80% of patients with significant blunt cardiac injury have other injuries. Comorbid injuries to the brain (42%–54%), aorta (47%–49%), lungs including hemothorax (44%–89%), ribs or sternum (26%–97%), liver or spleen (54%), kidneys (24%), and spine (37%) are the most common. ^, Conversely, features suggestive of blunt cardiac injury include hypotension on arrival (adjusted odds ratio, aOR 4.5), thoracic aortic injury (aOR 2.7), pulmonary contusion (aOR 2.5), rib fracture (aOR 1.4), sternal fracture (aOR 3.3), and hemothorax/pneumothorax (aOR 1.7).

Most stab wounds of the heart result in acute pericardial tamponade, although occasionally, rapidly exsanguinating hemorrhage may result. The patient thus usually presents with symptoms and signs of acute cardiac tamponade complicated by acute blood loss. (For a discussion of cardiac tamponade, see “ Acute Cardiac Tamponade ” under Clinical Features and Diagnostic Criteria in Section I of Chapter 18 .)

Missile wounds usually result in acute hemorrhagic shock, which may be rapidly fatal. If not, the patient enters the hospital profoundly hypotensive, with tachycardia and collapsed veins. Penetrating cardiac wounds are frequently accompanied by wounds involving the pleural space, the intrapericardial thoracic vessels, the lung, and occasionally by wounds of the liver and other abdominal viscera. Patients with cardiac contusion may exhibit no symptoms, precordial pain, or symptoms indistinguishable from those of angina (see Special Studies later in this chapter). Pericarditis and hemopericardium may develop as complications of cardiac contusion. The natural history then becomes that of these conditions (see Chapter 18 ), with possible late development of cardiac tamponade and chronic constrictive pericarditis.

In patients not requiring emergent thoracotomy, suspected cardiac injury is rapidly evaluated by chest radiography; significant findings include a widened cardiac or aortic silhouette and visualized bullets or projectiles. In addition, emergent echocardiography (Focused Assessment with Sonography in Trauma [FAST]) may demonstrate pericardial fluid/tamponade, valve injuries, and ventricular dysfunction. Physical examination signs, including Beck’s triad of muffled heart sounds, jugular venous distension, and pulsus paradoxus, are present in less than 10% of cardiac injury patients. Further evaluation using computed tomography angiography (CTA), detailed echocardiography, electrocardiography, and cardiac enzyme tests may be undertaken to detect other injuries.

Transthoracic echocardiography is the gold standard for evaluating a large spectrum of cardiac injuries. It allows for rapid, real-time diagnosis of cardiac injuries that may influence operative management. Echocardiography generally demonstrates excellent sensitivity (87%–100%) and specificity (97%–100%) for detecting penetrating injuries, many of which present with hemopericardium or cardiac tamponade. However, sensitivity may be as low as 50% in patients with multiple breaches of the pericardium or pleural cavities. This pattern is also seen in nontrauma literature, wherein sensitivity and specificity of echocardiography for detecting small-to-moderate pericardial effusion are 80% and 75%, respectively, compared to 100% and 100% for large effusions. Transesophageal echocardiography serves as an adjunct and may be used intraoperatively wherein other injuries are being addressed to assess concomitant cardiopulmonary injury.

In the absence of reliable echocardiography, pericardiocentesis and subxiphoid pericardiotomy may provide rapid evaluation and treatment of cardiac injury, but they are relatively time-consuming, and positive tests may lead to a larger, second operation that may not be needed. Pericardiocentesis and subxiphoid pericardiotomy have similar outcomes. ^{, ,} These techniques have largely been replaced by bedside ultrasonography, which shortens evaluation time and time to definitive care. ^, Nonetheless, subxiphoid pericardiotomy remains a valuable tool in the setting of stable patients with equivocal FAST findings and high clinical suspicion of cardiac injury.

Subxiphoid pericardiotomy is performed by creating a 5-cm vertical, midline incision centered at the xiphoid process. After skin and subcutaneous tissue are opened, the linea alba is incised, with care to not violate the peritoneal cavity. The xiphoid process itself is then freed from surrounding tissue, and careful dissection of the pericardial-diaphragmatic junction is undertaken. Once exposed, the pericardium is incised 1 to 2 cm, and the effluent fluid is assessed for signs of blood. The pericardial sac should be irrigated with warm saline thereafter to assess for active intrapericardial bleeding. Maintaining a bloodless field prior to pericardiotomy will minimize the likelihood of false-positive evaluation of intrapericardial bleeding.

Contusions are generally evaluated using a combination of cardiac enzymes and electrocardiography: a normal result in both investigations has a near 100% negative predictive value for cardiac injury. However, elevated troponin may be confounded by shock, hypoxemia, and noncardiac thoracic trauma. With the exception of sinus tachycardia, often due to other injuries, the most common arrhythmias observed are nonischemic ST segment and T wave abnormalities followed by RBBB. Other arrhythmias are seen with lower frequency. ^{, , ,} Pathologically, mild contusions may only cause epicardial petechiae, whereas more severe contusions may cause localized regions of myocardial necrosis, which may precipitate aneurysm, pseudoaneurysm, or wall rupture.

Dysrhythmias of different types may develop. Electrocardiographic abnormalities may be present shortly after injury or can be delayed 12 to 24 hours. Abnormalities may be transient or longer lasting, depending on extent of myocardial damage. ^, Q waves may develop similar to those seen in acute myocardial infarction. Myocardial enzymes may become elevated after injury and, if so, provide a near-positive diagnosis of cardiac contusion. However, the electrocardiographic and enzymatic criteria are relatively insensitive and nonspecific indicators of cardiac contusion.

The decision to perform EDT is based on the presence of signs of life (SOL), as well as life-threatening cardiothoracic injury, often in the context of impending or sustained cardiac arrest. Left anterolateral thoracotomy allows for multiple life-saving measures, including decompressive pericardiotomy in the context of hemopericardium and cardiac tamponade, control of thoracic aortic hemorrhage, open cardiac massage, and temporary repair of myocardial wounds.

Multiple studies have evaluated the utility and outcomes of EDT in cardiac trauma. ^{, ,} Generally, EDT is more beneficial in penetrating versus blunt trauma. A recent meta-analysis by Nevins and colleagues assessed 3251 patients with penetrating and blunt cardiac trauma and found an 8.5% mean survival. Significant survival advantages were observed in penetrating versus blunt trauma (OR 2.10), stab wounds versus gunshot wounds (OR 5.45), presence of SOL on admission (OR 5.36), and SOL in the field (OR 19.39). Liu and colleagues meta-analyzed 43 studies and reported a median survival of 17%. Risk factors for mortality included high injury severity score (ISS), low Glasgow Coma Scale (GCS), presence of multiple wounds, hypotension, pulseless electrical activity, and asystole. Rhee and colleagues reported a 25-year review of 24 studies assessing 4620 patients with an overall survival rate of 7.4%. Survival was significantly higher in penetrating versus blunt trauma (8.8% vs. 1.4%), stab versus gunshot wounds (16.8% vs. 4.3%), and SOL versus no SOL on arrival to a hospital (11.5% vs. 2.6%). Of note, if the location of major injury was the heart, patients had a 19.4% survival rate. A 5-year review of the Trauma Quality Improvement Program in the United States reviewed 2229 EDT patients and reported a 9.6% survival rate. Predictors of survival in this cohort were penetrating mechanism, age <60 years, SOL on arrival, lower ISS, and no prehospital CPR. Of note, there were no survivors older than 70 years and no survivors of blunt cardiac trauma older than 60 years. In penetrating trauma, EDT is more likely futile in the context of pulselessness greater than 15 minutes or asystole with no pericardial tamponade. In blunt trauma, EDT is likely futile if the patient has received more than 10 minutes of prehospital CPR.

Taken together, the body of literature has led to guideline indications for EDT ( Fig. 16.2 ). For both penetrating and blunt injuries, EDT is generally justified for patients with hemodynamic instability refractory to appropriate fluid resuscitation, cardiac arrest in transit to or during initial resuscitation, rapid exsanguination from chest drains (>1500 mL immediately returned), or cardiac tamponade. In penetrating trauma, EDT is also justified for patients who are pulseless for less than 15 minutes before receiving CPR, although some advocate for EDT irrespective of length of pulselessness as long as the patient shows SOL. Critically, EDT should only be performed in settings where definitive surgical management (trauma and/or cardiothoracic surgery expertise) can be provided, as attempts to transport these patients are largely unsuccessful.

Initial anterolateral thoracotomy during resuscitation and exploration can be extended across sternum (clamshell thoractormy) to give adequate access for repair of cardiac injury.

(From Watson LJ, Coyne P. Resuscitative thoracotomy. Surgery. 2021;39:423–429.)

Left anterior thoracotomy is the incision of choice for EDT and is performed in the supine patient with arms abducted to 90 degrees on arm boards and the breasts retracted cephalad as needed. The incision is made from the sternal border of the fourth or fifth intercostal space to the corresponding posterior axillary line, often corresponding to the start of the bed. Any remaining subcutaneous tissue, intercostal muscles, and pleura are then incised with a knife or scissors. A rib retractor (e.g., Finochietto) is then placed with the joint faced laterally (downward). To optimize exposure, extension of the incision, as well as temporary right mainstem ventilation, may be employed. In the setting of concurrent right-sided thoracic injury or inability to visualize cardiac injuries, the decision can be extended into a right anterior thoracotomy, known as a “clamshell” thoracotomy, across the sternum (see Fig. 16.2 ).

Attention should be paid to the internal mammary arteries, which may spasm at the time of transverse sternotomy but may bleed later if not ligated or clipped. Median sternotomy remains the incision of choice for evaluation and management of cardiac injuries if the patient is stable. If trained surgeons are in attendance and the repair appears to be a simple one, repair is then performed. Otherwise, the patient is transferred to a prepared operating room while digital control of the hemorrhage is maintained. If digital control of the hemorrhage is not possible, survival is unlikely and any further intervention inadvisable.

When a patient presents with a penetrating wound of the chest in a location and direction that could involve the heart, the assumption is made that a penetrating wound of the heart exists. Resuscitative measures, including endotracheal intubation, volume replacement, and insertion of chest tubes, are performed promptly on admission to the emergency department, except in stable patients without shock or respiratory distress.

Patients with stab wounds of the heart and great vessels usually survive when treatment is adequate, except for those in extremis on admission (most of whom have suffered immediate massive hemorrhage from laceration of a great vessel). If the stabbing device is still in place when the patient is admitted to the emergency department, it is not removed until the incision is made and, ideally, not until the pericardium is opened.

When the patient arrives in the emergency department unconscious and without vital signs or semiconscious with gasping respirations, a thready pulse, and no blood pressure, and all evidence points to a cardiac or great vessel wound as the cause, prognosis is poor. Immediate thoracotomy, as described before, is indicated if the emergency department is prepared for this type of major surgery. If not, a large-bore needle (13F) is inserted into the pericardial space through the subxiphoid route, and the patient is transported rapidly to an operating room. Because of the pathophysiology of acute cardiac tamponade (see Chapter 23 ), removal of even 40 to 50 mL of blood usually improves the hemodynamic state, at least temporarily. When the patient is in shock but has vital signs, a pericardiocentesis is performed as described, followed by rapid transfer to the operating room. When the patient’s condition is stable and a cardiac stab wound is only suspected, investigation can be accomplished in the emergency department or in the operating room if a noncardiac procedure is indicated. This evaluation is best performed by transesophageal echocardiogram.

Once in the operating room, the patient is rapidly anesthetized, prepared, and draped for operation. A large-bore needle is placed in an easily accessible large vein as these preparations are being made. Surgical draping should be wide, with the chest and abdomen fully exposed. Median sternotomy is made, and the pericardium opened. (In institutions in which cardiac surgery is not frequently performed, an anterolateral incision, usually left-sided, is made because this incision can be made rapidly and is the most generally useful.)

Blood is rapidly aspirated from the pericardial space with high-vacuum suckers. Ventricular wounds are best controlled initially by digital compression. Atrial and caval wounds are generally not well controlled in this manner, and wide Allis (Allis-Adair) clamps serve ideally to establish hemostasis by apposing the wound edges. If this is not possible or if the wound edges tear after application of clamps, a Foley catheter with a large balloon volume can be inserted into the cardiac chamber or vein and inflated. Only after digital or instrumental control of active bleeding has been accomplished should attention be turned to suturing the wounds. At this time, physiologic resuscitation should be completed. Blood volume is reconstituted with donor-specific matched or unmatched type O-negative blood to augment previously infused crystalloid or colloid, and blood pH is restored toward normal with bicarbonate. Supplemental calcium is usually given.

Ventricular wounds are best sutured with interrupted pledgeted mattress sutures of No. 2-0 or 3-0 polyester or polypropylene. A great danger in myocardial lacerations is their enlargement by the act of passing sutures in a fully filled and beating ventricle. It is often appropriate to induce inflow occlusion to empty the heart and provide a quieter field. After an interval of hyperventilation, the vena cavae are occluded using vascular clamps or snares, followed by clamp occlusion of the ascending aorta after the heart has emptied a few beats later. The cardiac wound is sutured over the next 2 to 3 minutes, and the caval and aortic clamps are then released. The heart will have continued to beat slowly during the occlusion period. Occasionally, a ventricular laceration is so extensive that it requires cardiopulmonary bypass (CPB) and patch-grafting of the ventricular free wall.

Wounds near a major coronary artery are similarly sutured, with pledgets on both sides of the artery and the sutures passing beneath it. If the left anterior descending coronary artery has been damaged, a coronary artery bypass graft should be placed (see Chapter 9 ). Atrial or caval wounds are closed by continuous No. 4-0 or 5-0 polypropylene sutures. Suturing is done beneath the clamp or carefully over the top of the inflated balloon of a Foley catheter, and the clamp is removed (or balloon deflated) only after the suture line is largely in place.

Unless there is near certainty that the pleural spaces have not been violated, both are opened widely through the median sternotomy. The internal thoracic arteries, a potential source of hemorrhage, are examined and, if damaged, are ligated by suture. Damaged areas of lung are oversewn or stapled. The hilum of each lung is examined for injury to the pulmonary vessels.

Drainage catheters are placed in each pleural space (see “ Positioning Chest Tubes ” under Completing Cardiopulmonary Bypass in Chapter 2 ), and one may be placed in the pericardial space as well. If hemostasis within the pericardium has been satisfactory, the pericardium is loosely closed with widely spaced interrupted sutures. The sternotomy is closed in the usual manner (see Section III of Chapter 2 ).

Patients with missile wounds of the heart are far less likely to survive than those with stab wounds. Patients who are unconscious or without vital signs or who are semiconscious but without measurable blood pressure should receive immediate thoracotomy if the emergency department is properly prepared. Patients not meeting these criteria for operation in the emergency department are transported immediately to the operating room. Principles of management are the same as described for stab wounds, but the result is less often successful.

Patients with cardiac rupture often present in extremis and require immediate surgical intervention in the emergency department or upon rapid transfer to the operating room, and preparations must be made for CPB. In those stable enough to receive further diagnostics or in cases of diagnostic uncertainty, echocardiography remains an invaluable tool for real-time assessment of septal or free wall ruptures. CT angiography is also a useful adjunctive imaging modality and may demonstrate shunts. In the operating room, if the patient’s condition permits, the femoral artery is exposed and cannulated (after heparinization) before median sternotomy. After median sternotomy, it may be seen that the rupture involves only a small area. In that case, digital control and placement of pledgeted mattress sutures suffice. Larger defects may require adjunctive measures, including insertion of a balloon catheter into the heart defect or temporary inflow occlusion of the venae cavae to lessen blood loss and lower chamber pressure for safer repair. Some simple atrial lacerations can be controlled by placing a Satinsky clamp to exclude the defect and facilitate repair, depending on location of the injury. Ventricular lacerations are repaired with polypropylene sutures on a large needle (often with pledgets) in a horizontal mattress fashion; care should be taken to avoid injury to or ligation of major epicardial coronary arteries.

If the injury is directly beside a coronary artery, sutures should be passed parallel to the artery, but sometimes deep horizontal mattress sutures are passed deep behind the coronary artery in transverse orientation to control bleeding but not interfere with coronary flow. ^, If the defect is large and digital control cannot be obtained, CPB is established; blood is aspirated from the pericardium for venous return, and a reduced systemic blood flow rate is used. As soon as a single venous cannula can be inserted into the right atrium, CPB is converted to usual techniques and flow rates. Repair of the free wall rupture is improvised but, in the case of the ventricle, is generally similar to repair of a myocardial rupture complicating acute myocardial infarction (see Chapter 10 ). Catheter closure of defects is possible, but experience is limited, and more often, it is employed for chronic defects not recognized at the time of injury.

Tissue quality in cardiac wall injury is influenced by mechanism of injury: after a stab wound, cardiac tissue is usually normal, but gunshot wound and blunt injury may result in necrosis and result in tissue quality similar to myocardial infarction. Posttraumatic VSDs and traumatic injuries of the tricuspid valve are managed in a manner similar to that for congenital and postinfarction VSDs and other types of tricuspid valve regurgitation (see Chapters 10 , 14 , and 35 ). Small VSDs can be closed primarily or with a bovine pericardial or polyester patch, whereas larger VSDs necessitate patch repair. There is no need for delay in most cases unless the shunt is small and the cardiac function is otherwise normal in a stable patient. ^,

In tricuspid valve rupture, the tensor apparatus is usually involved. An attempt should be made to reconstruct the leaflets using pericardium and the tensor apparatus using artificial chordae of polytetrafluoroethylene (PTFE) suture. For trauma to the mitral valve, repair, if possible, is advised (see “ Repair of Mitral Regurgitation ” under Technique of Operation in Chapter 11 ). Occasionally, mitral valve replacement is necessary. In the rare case of rupture of a single aortic valve cusp, repair is possible; when two cusps are involved, valve replacement is usually necessary.

The presence of a penetrating wound to the heart is an indication for immediate operation. A stab wound over the heart without bleeding or hypotension may indicate that no penetration has occurred and is, therefore, not an indication per se for operation. Transesophageal echocardiography is helpful in this situation.

Occasionally, patients convalesce apparently satisfactorily and without special treatment (usually a stab wound rather than injury by a missile), only to come to medical attention weeks to years later because of a murmur or heart failure. Special studies usually demonstrate a VSD, laceration of a cardiac valve, or aorta–to–pulmonary artery or aorta–to–brachiocephalic vein fistula. Operation is indicated, and a good result can usually be obtained.