Definition & Overview
Penetrating cardiac wounds are usually sustained from gunshots and stabbing. These can cause cardiac bleeding with or without tamponade, embolus to a peripheral artery, and myocardial infection, which are all life-threatening conditions that require immediate medical attention.
Who Should Undergo and Expected Results?
Cardiac wound repair is indicated for patients with moderate to severe and life-threatening heart trauma or injury. Any wound in the heart, particularly those caused by gunshots and stabbing, are considered life-threatening. Thus, immediate medical intervention is crucial for the patient’s survival.
As for the expected results, the outcomes of the procedure largely depend on the severity of the injuries and how soon treatment is provided. Patients who are in stable condition before the surgery can expect a full recovery. However, those with unstable condition even before they receive medical attention may not survive the procedure.
How is the Procedure Performed?
The management of cardiac wound requires an incision in the chest wall (median sternotomy). But prior to that, pre-operative procedures such as chest x-ray or fluoroscopy are performed to fully visualise and better assess the injured area and surrounding organs. The images produced allow surgeons to look inside the traumatised area before the actual invasive procedure begins.
The procedure to repair cardiac wounds is highly risky and is performed under general anaesthesia. The mortality rate can be as much as 80%.
The heart has four chambers or compartments. These are the left and right atriums and the left and right ventricles. The right ventricle is the most prone to injuries as it is in close proximity to the surface of the chest wall. However, injuries can affect multiple parts of the heart at any given time.
The primary goal of the treatment is to stop bleeding. This is achieved through cardiorrhaphy, or the process of suturing the affected area of the heart. The procedure involves opening the chest wall (thoracotomy) to gain access to the heart. The pericardium presents itself immediately after opening the chest wall and provides useful clues on the extent of injuries.
Most techniques involve the removal of the pericardium (pericardiotomy) to release mounting pressure inside the heart. Blood clots in the area are also removed to fully examine the site of injury and begin stitching up the injured tissue to stop bleeding.
Depending on the extent of the injury and the patient’s unique circumstances, the procedure to repair cardiac wound can be performed with or without cardiopulmonary bypass, a technique that temporarily takes over the function of the lungs and heart during surgery. Its goal is to maintain oxygen and blood circulation. In some cases, it can increase the patient’s chances of surviving the procedure but it can also lead to the development of serious complications. As such, surgeons may opt for an off-bypass technique to avoid the adverse effects of using a heart-lung machine that can contribute to postoperative morbidity and mortality.
Postoperative procedures require the patient to stay in the hospital for several days to drain excess blood and other fluids. An IV is attached to the patient throughout this period. These tubes are removed one by one as the patient’s haemodynamic profile improves. Haemodynamics relates to the overall flow of blood within the organs and tissues of the body.
Penetrating cardiac wounds typically affects the skin, breastbone, and the heart itself. The superficial skin should heal before the surgeon discharges the patient. However, the breastbone beneath may take around six to eight weeks to fully heal depending on the patient’s age and whether or not the patient has pre-existing disease. The surgery typically leaves a visible scar, but it is expected to dramatically improve within a year’s time.
Recovery from cardiac wound surgery takes time and each patient recovers at a different pace. In general, the recovery period takes an average of 12 weeks.
Following the surgery, patients may be advised to join a comprehensive rehabilitation programme, which components include dealing with stress, exercise, and reducing risk factors to hasten the recovery process.
Possible Risks and Complications
Cardiac surgery is a highly invasive medical procedure that is associated with both common and serious risks and possibilities of complications. These include:
- Stroke or heart attack
- Irregular heartbeat (arrhythmia)
- Kidney or lung failure
- Chest pain
- Breathing difficulty
- Blood loss, which may create the need for a blood transfusion
- Blood clot
- Memory loss
Also, the risk of infections is very high. Thus, it is very important to check on the incisions periodically to look for early signs of infection. The superficial wound would sometimes indicate any underlying infections. If patients notice any of the following signs, they must see their surgeons as soon as possible:
- Swelling, redness, or oozing fluid from the site of incisions
- Gaping or opening of the wound/incision line
- Feeling of warmth along the incision line
Patients normally feel an itching or tingling sensation in the area where the incision was made. Itching is brought about by the activation or irritation of nerves around the wound while it goes through the normal healing process. It could also be due to the release of histamines in the affected area.
Histamines are organic compounds involved in the immune response. The body deploys white blood cells to the area of the wound to fight invading pathogens (disease-causing germs) and release histamines during the process.
The activated nerves send signals to the brain, and the brain interprets it as an itch and would, therefore, want to respond by scratching the surface of the wound.
US National Library of Medicine National Institutes of Health; “Penetrating heart wounds repaired without cardiopulmonary bypass. Evaluation and follow-up of recent war injuries”; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC325069/
Kunz SN, Arborelius UP, Gryth D, Sonden A, Gustavsson J, Wangyal T, et al. Cardiac Changes After Simulated Behind Armor Blunt Trauma or Impact of Nonlethal Kinetic Projectile Ammunition. J Trauma. 2011 Nov. 71(5):1134-1143.