Year : 2018 | Volume
: 3 | Issue : 1 | Page : 3--4
Controversies in cardiac trauma
Kenneth L Mattox
Distinguished Service Professor, Division of Cardiothoracic Surgery, Baylor College of Medicine, Chief of Staff and Surgeon-in-Chief, Ben Taub Hospital, Houston, Texas, USA
Kenneth L Mattox
Distinguished Service Professor, Division of Cardiothoracic Surgery, Baylor College of Medicine, Chief of Staff and Surgeon-in-Chief, Ben Taub Hospital, Houston, Texas
|How to cite this article:|
Mattox KL. Controversies in cardiac trauma.J Cardiothorac Trauma 2018;3:3-4
|How to cite this URL:|
Mattox KL. Controversies in cardiac trauma. J Cardiothorac Trauma [serial online] 2018 [cited 2023 Jan 28 ];3:3-4
Available from: https://www.jctt.org/text.asp?2018/3/1/3/248104
The editor of this journal has asked I write a provocative editorial on a few of the controversies involved in cardiac trauma to stimulate intellectual surgical dialog. For focus and brevity, I will address the question of which procedure is most beneficial following acute cardiac trauma in 2018 – percutaneous needle pericardiocentesis or subxiphoid pericardial window? For the millennial readers, seeking instantaneous gratification, I could complete this editorial with one word - “NEITHER”! The surgeon, presented with a dying patient following thoracic trauma, needs to know the correct approach for the best functional outcome is – immediate left anteroateral thoracotomy through standard techniques.
In 2018, however, the intellectual surgeon, emergency physician, intensivist, or educator mandates and deserves a more cognitive and reasoned editorial, which includes physiologic and historic perspectives on how we have arrived at a practical approach to this cardiac trauma controversy. I will attempt to demonstrate why, for trauma, pericardiocentesis and subxiphoid pericardial window should be relegated to “never events” in the curiosity section of medical and surgical museums.
Thoracotomies, endotracheal anesthesia, emergency medicine, surgical critical care, imaging, and physiologic approaches to disease interventions are, principally, products of the 20' century. The earliest series of cardiac trauma patients reported from hospitals were based on rather minor stab wounds that penetrated the pericardium and/or heart but did not result in immediate large and fatal pericardial tamponade. Many of these were puncture/ice pick type wounds, where the cardiac bleeding soon stopped as the pressure from the hemopericardium increased. Many patients presented later, as the blood in the pericardial sac became defibrinated, and the nonclotting remaining blood could easily be aspirated. However, a rind of fibrin often remained around the heart but could be tolerated physiologically. Sometimes, such chronic cases required open surgical removal of this fibrotic calcific constriction (constrictive pericarditis). In such cases, a thoracotomy was not only unnecessary, but with rudimentary thoracic surgery techniques, such as open surgery, this procedure also had its own complications and mortality. In those early days, the logical recommendations for these cases were, quite appropriately, needle pericardiocentesis. Should the probing needle go beyond the pericardium and enter a cardiac ventricle, the puncture wound soon and most often, sealed off, and the proceduralist never knew of the minor iatrogenic injury to the heart.
By the early 1960's, thoracic and cardiac surgery was becoming quite sophisticated. In emerging trauma centers, thoracic surgeons were called on to acutely evaluate and treat patients with thoracic trauma. Techniques in thoracotomy and the several positions and incision options were well understood by these thoracic surgeons. Surgical publications emerged establishing left anterolateral thoracotomy replacing needle pericardiocentesis as the treatment of choice. This recommendation is especially germane for the ACUTE HEMOCARDIUM that follows trauma and always contains clotted blood, which can never acutely be removed by a probing percutaneous needle. Furthermore, even among those early series and continuing in later reports at open thoracotomy, it was found that the offending hole in the heart was an iatrogenic injury caused by the pericardiocentesis needle. This discovery has anecdotally continued as trauma centers have developed and surgeons less comfortable and skilled in open thoracotomy have reverted to seek simpler techniques. Thoracic surgeons have been less keen to be the trauma surgeons on call for thoracic trauma conditions.
In the 1970's, publications described techniques, and there were feasibility studies, (rather than outcome comparative efficacy studies) on alternative techniques to the overly simple pericardiocentesis or the less commonly performed formal open thoracotomy being performed by general surgeons. Those general and trauma surgeons who reported series of cardiac wounds were also extensively trained in thoracic surgery. There appeared to be a desire to find an intermediary procedure that any general surgeon could perform with speed and safety while releasing a pericardial tamponade and repairing the offending cardiac injury. Thus, the subxiphoid pericardial window emerged and received some popular support. However, this was not such a simple procedure, was not performed very quickly, had extremely limited exposure, did not allow for repair of cardiac wounds, and did not produce results better than immediate and expeditious left anterolateral thoracotomy. While it is true that one can get into the pericardial sac from such an approach, it is like sending a boy to do a man's job. At the same time, some surgeons also proposed entering the pericardium through a generous laparotomy and then performing a transabdominal, transdiaphragmatic pericardiotomy from the mid portion of the diaphragm through the abdomen and making a large generous incision so repair of ventricular lacerations and punctures could be attempted. This latter approach is totally different from the subxiphoid pericardial window. It is performed after a surgeon has performed a laparotomy, has determined the source of continuing hypotension in the abdomen, and might have found a diaphragm bulging into the abdomen.
It is true that a subxiphoid pericardial window can allow aspiration of clotted blood; however, it does not allow for precise repair of a cardiac injury, so another incision (anterolateral thoracotomy or median sternotomy) is then required to repair the cardiac puncture or approach other causes of the hemopericardium. At times, an anterolateral thoracotomy is extended into a bilateral transsternal anterolateral (trapdoor) incision to obtain adequate exposure. In comparative observations in the same institution, the time required for an anterolateral thoracotomy is shorter than time required for the formal thoracotomy. This observation speaks against the utility of the subxiphoid pericardial window.
A complete list of the many controversies relating to cardiac trauma is inappropriate in this editorial. It is important to address and/or contrast two of the most contentious of these many controversies – percutaneous needle pericardiocentesis or subxiphoid pericardial window. The operative word for this editorial is clearly the recommendation – NEITHER.