Case Report

Successful management of penetrating cardiac injury under guidance of transesophageal echocardiogram

Abstract

Penetrating cardiac injury is a rare medical emergency but with very high mortality. A quick and clear diagnosis and treatment strategy is of paramount importance in this emergency situation. Intraoperative transesophageal echo- cardiogram (TEE) is now considered to have an important role to play in this process. We then presented a case of a 42-year-old man who had 2 Stab wounds and arrived in emergency department with Altered consciousness, two 4- cm laceration over his left fourth intercostals space near the cardiac apex, and eighth intercostals space in posterior axillary line; blood pressure was maintained 74/40 mm Hg with infusion of vasoactive drug and colloid. transthoracic echocardiogram image was difficult to obtain and only showed the mass cardiac tamponade with thrombus in the apical of the pericardium. However, under the guidance of the TEE, clarified internal heart and pericardium structure were visualized with no valvular structure, interventricular septum, ventricular wall, and great vessel damage. Only massive thrombus was noted at the posterior part of heart apex. This heart injury was then successfully treated through left thoracotomy without cardiopulmonary bypass. It further proved that TEE can play a pivotal role in evaluating the internal heart injury as well as selecting the surgical strategy in this critical situation.

A 42-year-old man who had 2 stab wounds to his chest was driven to emergency department room. Two 4-cm laceration over his left fourth intercostals space near the cardiac apex and eighth intercostals space in posterior axillary line were noted during inspection. Patient was altered consciousness (Glasgow Coma Scale score of 9) with blood pressure of 80/50 mm Hg and heart rate of 135 beats/min. Respiratory and heart sound cannot be auscul- tated in left lung field, electrocardiogram shows supraven- tricular tachycardia with multiple ventricular rhythm. SpO2 was approximately 86%. Severe internal jugular distention was also noted. Heart beat can be palpated through chest wound in the fourth intercostals space, emergency trans- thoracic echocardiogram (TTE; iE33 Philips, Philips Medical system, Andover, Mass, with S5-1 probe) was

failed in parasternal window and cardiac tamponade was confirm using subxiphoid window with massive thrombus, However, noninternal cardiac structure can be visualized by TTE (Fig. 1).

Patient was immediately transferred to the operation room while his blood pressure dropped to 50/30 mm Hg measured by invasive blood monitor in Radial artery. Vasoactive drug and 600 mL 6% hydroxyethyl starch were infused via 2 16G venous line, and blood pressure increased to 80/40 mm Hg. Anesthesia induction was done by etomidate and vecuronium with cardiopulmonary bypass (CPB) standby. Transesophageal echocardiogram (TEE; iE33 Philips, Philips Medical system, Andover, Mass, with X7t-2 probe) showed only mild to moderate cardiac effusion in midesophageal 4-chamber view and long-axis view (Fig. 2). Cardiac tamponade with massive thrombus was noted at the posterior part of heart apex (Fig. 3). Four-heart-chamber valvular structure, interven- tricular septum, ventricular wall, and great vessel were clearly visualized, and nonabnormal image was noted. Then the surgeon chose lateral thoracotomy via the upper border of the fourth rib to directly repair the heart without CPB. After thoracotomy, 800 to 1200 mL bloody pleural effusion was sucked out, and pericardial was cut with approximately 400 mL cardiac effusion. Large thrombus was removed from the back side of the heart. Blood pressure was elevated gradually to 110/70 mm Hg. Two

Fig. 1 TTE showed cardiac tamponade with massive thrombus through subxiphoid window.

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986.e6 Case Report

Fig. 2 Only mild to moderate cardiac effusion was showed without internal structure damage through TEE midesophageal 4- chamber view.

ventricular lacerations were inspected and repaired with 4-0 polypropylene suture, one is 1.5-cm laceration in the anterior surface of left ventricular just lateral to left descending coronary artery and the other is 1-cm laceration at the back side of the heart just opposite with anterior lesion. After TEE examination, no other internal lesion was notice, chest wall was then closed, and the patient was transferred to the intensive care unit. Postoperative echo showed only mild cardiac effusion, and patient was discharged 1 week later.

Penetrating cardiac injury is a rare medical emergency but with very high mortality [1]. For patients with penetrating heart injury, early clarified diagnosis and treatment strategy are life saving [2]. In this process, TEE plays a critical important role, compared with the routine transthoracic images, which may be difficult to obtain and inadequate in seriously ill patients especially for those with severe left lung pneumothorax. Transesophageal echocardiogram has been recognized as a essential tool for the perioperative

Fig. 3 TEE revealed massive thrombus at the posterior part of heart apex in Transgastric short axis view.

identification of injuries in the setting of cardiac trauma because of its better delineation of myocardial internal structures and tamponade condition [2,3]. Just like this patient, due to severe pneumothorax, TTE image was only obtained in subxiphoid window with only cardiac tamponade confirmed and no information about internal structure inside the heart. On the contrary, TEE clearly showed more detail information such as loci of the tamponade, heart function, and, more importantly, the internal structure and great vessel condition of the heart.

In the case of heart injury, this important information can largely facilitate the clinical judgment about whether immediate CPB is necessary. Kang et al [2] list in his article about the circumstances in which cardiopulmonary bypass is indicated including valvular injuries, large intracardiac septal defect, retained intracardiac projectiles, coronary-cameral fistula, large ventricular wound, as well as great vessel injury. In this patient, no such lesion was noted before the surgery via TEE, and the tamponade thrombus was mainly located in the back side of the heart. Instead of immediate CPB, a lateral thoracotomy was the first-hand choice to resolve the tamponade and repair the ventricular injury [4]. On the contrary, if clarified internal structure lesion, coronary artery injuries, Retained projectiles, or large ventricular wound were noticed, CPB should be built as soon as possible.

To our knowledge, this is the first case in which penetrating heart injury was successfully managed under the guidance of TEE. It further proves that TEE can play a pivotal role in evaluating the internal heart injury, selecting the surgical strategy in this critical situation, and increasing the successful rate for this fatal but treatable disease.

Hai Yu MD Da Zhu MD Peng Liang MD Bin Liu MD

Department of Anesthesiology West China Hospital, Sichuan University

Chengdu 610041, Sichuan People‘s Republic of China

E-mail address: [email protected] doi:10.1016/j.ajem.2010.01.018

References

1. Campbell NC, Thomso SR, Muckart DJ, et al. Review of 1198 cases of penetrating cardiac trauma. Br J Surg 1997;84:1737-40.
2. Kang N, Hsee L, Rizoli S, et al. Penetrating cardiac injury: overcoming the limits set by nature. Injury 2009;40:919-27.
3. Deshmukh HG, Khosla S, Jefferson KK. Direct visualization of left ventricular free wall rupture by transesophageal echocardiography in acute myocardial infarction. Am Heart J 1993;126:475-7.
4. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in Thoracic trauma-a review. Injury 2006;37:1-19.