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Interactive Cardiovascular and Thoracic Surgery 2:53-57(2003)
© 2003 European Association of Cardio-Thoracic Surgery

Institutional review - Cardiac general

Trauma to the heart and thoracic aorta: the Copenhagen experience

Moheb A. Rashid* and Jens T. Lund

Department of Cardiothoracic Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark

* Corresponding author. Hagforsgatan 71, 416 75 Gothenburg, Sweden. Tel.: +46-31-256985; fax: +46-707-691067
moheb_rashid{at}hotmail.com

Received August 9, 2002; received in revised form November 4, 2002; accepted November 7, 2002


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Injuries of the heart and thoracic aorta (traumatic aortic rupture, TAR) remain amongst the most challenging of all injuries seen in the field of trauma and cardiothoracic surgery. The aim herein was to present our experience of such lethal injuries treated at Denmark's busiest hospital. We found 11 patients with cardiac injuries and nine patients with TAR. Five patients with cardiac injuries presented in shock of which two died. Eight patients with TAR were operated on using bypass without paraplegia. The Danish experience of heart trauma is limited but with satisfactory results. We recommend left heart bypass to prevent paraplegia in TAR.

Key Words: Cardiac and aortic injuries; Urgent thoracotomy and sternotomy; Left heart bypass; Paraplegia; Mortality


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
The Egyptians were the first to describe medicine in general and trauma to the heart and aorta in particular as shown in the Edwin Smith surgical Papyrus written by the Egyptian Imhotep more than 5000 years ago [1]. The heart since that time has inspired many talented poets, writers and musicians not only in Egypt but all over the world. Patients with trauma to the heart often require immediate surgical intervention, excellent surgical technique and well performed postoperative care. Traumatic transection of the thoracic aorta also requires a meticulous way of assessment and management, because its diagnosis is difficult, its mortality is high, and its morbidity is tragic particularly when trauma victims are mostly below the age of 40. Paraplegia is a dreaded complication, which is related to the bad protection of the spinal cord during management, and the situation can be a medicolegal problem to the surgeon and a tragedy to the young patient. Currently, most knowledge involving injuries of the heart and thoracic aorta comes from American studies [2,3] or South African series [4,5] due to the increased violence in these societies compared with Europe. This issue is yet to be defined in Scandinavian countries, therefore we performed this study to find out if we could characterize such injuries in Denmark's busiest medical center (Rigshospitalet) in Copenhagen and to present our experience with such lethal injuries.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 Appendix A
 References
 
We found 19 patients with heart or thoracic aortic injuries; one had both cardiac and aortic lesions. Cardiac injuries were found between May 1995 and June 2001, while aortic injuries were found between March 1996 and August 2000. There were 11 patients with cardiac injuries, of whom three were iatrogenic. Of the remaining eight patients (mean age 37 years, range 16–63 years) four had penetrating injuries, and four had blunt injuries. Of nine patients with thoracic aortic injuries, one was iatrogenic. The remaining eight patients (mean age 50 years, range 31–69 years) were meticulously analyzed. We collected the following data: mechanism of injury, age, sex, clinical presentation, risk factors, methods of investigations, surgical techniques, associated lesions, morbidity, mortality and follow-up. The injury severity score (ISS) was calculated for all patients.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 Appendix A
 References
 
3.1. Cardiac injuries

The mechanism of injury was a knife stabbing wound in penetrating injuries of the heart (), motor vehicular crash (MVC) in three, and door edge in one. Fifty percent of patients had alcohol and/or drug misuse and suicide as risk factors. The time between wounding and arrival at the hospital was minimal and recorded as immediately in six patients while it took 43 and 45 min in two other patients. All five patients with penetrating or ruptured cardiac injuries presented with one or more components of Beck's triad [6]. The ISS average was 19 (range 9–42). The penetrating wounds involved the right ventricle and left ventricle ( each). A blunt rupture of the right atrium was found in one case and myocardial contusion in three. Patients with cardiac penetration or rupture () presented in shock and underwent urgent surgery (Table 1). The three patients with blunt cardiac injury had ST/T wave changes, arrhythmias and raised creatine kinase isoenzyme. The average length of hospital stay in the intensive care unit (ICU) was 2 days (range 1–5 days), and in the ward 3 days (range 2–16 days). In all patients with penetrating or ruptured cardiac injuries () there was hemothorax (two right, two left, and one bilateral), and all had pericardial tamponade. The mortality among patients with cardiac and aortic injuries is shown in Table 2.


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  		Table 1 Surgical procedures for patients with cardiac penetration or rupturea

 

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  		Table 2 Mortality among patients with cardiac injuries (the second patient had combined cardiac and aortic lesions)

 
3.2. Aortic injuries

The mechanism of injury was MVC in all patients () with traumatic aortic rupture (TAR). The time between wounding and arrival at the hospital was minimal and recorded as immediately in six cases while it took 37 and 45 min in two other cases. All patients with aortic lesions were operated on between 2 and 24 h following trauma, and the tear was found in the classic position ‘isthmus’ of the descending thoracic aorta. Seven patients were operated on using left heart bypass with the BioMedicus pump (Medtronic Inc., Minneapolis, MN) (left atrial to descending aorta in six and left atrial to left femoral in one) and one patient was put on cardiopulmonary bypass because of respiratory insufficiency due to bilateral severe pulmonary contusions. The average ischemic time was 21 min (range 13–52 min). A Hemashield graft (Meadox; Boston Scientific Corp., Oakland, NJ) was inserted in seven patients and one was sutured directly. One patient had postoperative renal failure, but no incidence of paraplegia or cardiac failure. The average length of hospital stay in the ICU was 2 days (range 2–4 days), and in the ward 6 days (range 8–15 days). Only one patient died due to cerebral damage 4 days after successful aortic repair, and his death was not directly related to the repair. The diagnostic methods used in the detection of TAR are shown in Table 3. The iatrogenic cardiovascular injuries are presented in Table 4.


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  		Table 3 The diagnostic tools used in the detection of aortic lesionsa

 

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  		Table 4 Patients with iatrogenic cardiovascular injuries (three cardiac and one aortic)a

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
Appendix A
 References
 
4.1. Cardiac injuries

In this study, alcohol or drug abuse and suicide were significant risk factors and there were no gunshot wounds in this discrete number of patients who reached the hospital alive with such injuries. This is consistent with the Swedish experience of heart trauma [7,8]. All patients with penetrating or ruptured cardiac injuries presented with one or more components of Beck's triad [6] consisting of distended neck veins, muffled heart sounds and hypotension. This was the classic clinical presentation of pericardial tamponade that was confirmed at surgery. Pericardial tamponade in this series showed both good and bad effects and acted as a double-sword. In patients with blunt cardiac injuries, echocardiography has also shown several limitations being difficult to perform in a badly-positioned patient with chest wall tenderness, the presence of hemothorax and/or pneumothorax adds more difficulties with poor quality, and this probably adds nothing as a screening test in such patients [9]. Similarly, our results showed no advantage of echocardiography and the clinical picture was consistent with tamponade, which was confirmed during surgery. We have recently observed that echocardiography was not helpful in patients with cardiac injuries and it gave false negative results in one patient who had tamponade clinically and proven at surgery [7]. In the present study, this may be explained by the fact that all patients with penetrating or ruptured cardiac injuries had pleural breach with hemothorax. One patient had bilateral pleural breach and died from exanguination. Consistent with other reports [4,7], we consider that pleural breach with hemothorax is a risk factor for death in patients with penetrating or ruptured cardiac injuries. The incidence of myocardial contusion was small (3/8) due to the difficulty in the diagnosis of such an entity that is sometimes indistinguishable from associated injuries in patients with multitrauma as shown in this study and previous series [7,8]. We had two patients who died and the cause of death was not directly related to the cardiac or aortic repair (Table 2). Of those who died, there was one patient who underwent an emergency room thoracotomy because of abrupt severe hypotension in the emergency room and died from intractable bleeding during surgery, particularly from the injured right pulmonary hilum. Our data reflect the Danish experience of heart trauma: there were few cases, alcohol and drug misuse and suicide are the principal risk factors, and there were no cases with commotio cordis or gunshot wounds.

4.2. Aortic injuries

TAR is the second most common cause of death in blunt trauma patients [3]. A South African report [5] has estimated that the average number of patients with TAR per trauma center per year was 2.6 (range 0.2–10.7) in a twenty-year metaanalysis study and found only 1742 patients who reached the hospital alive. The diagnosis of TAR is not an easy task. In this study, we found that the chest radiographs (CXR) gave an early clue to the suspicion of TAR in 6/8 (75%) cases, and the widened mediastinum was the most frequently cited CXR finding that triggered further work-up. Most CXR in cases with blunt chest trauma may show evidence of mediastinal abnormalities leading to aortography according to the Advanced Trauma Life Support protocols of the American College of Surgeons. These radiographs are often performed in bad conditions in a typical multitrauma patient with injuries caused by MVC. Although CXR are useful and may lead to the proper method of reaching the diagnosis of TAR as clearly shown in this study, a critical and careful examination of these radiographs is important. Recently, we proposed a schedule for a better selection of patients going to aortography in the multitrauma setting with some mediastinal abnormalities. This schedule definitely spares many unnecessary transports and angiographies, and is thereby cost-effective [8]. Angiography is a very sensitive, specific and accurate test for the diagnosis of TAR, and it is still the ‘gold standard’ of diagnosis [10]. We performed angiography in four patients and showed TAR in all of them (Table 3). TAR is rarely a single lesion and the surgeon must decide without delay which comes first, thoracotomy, laparotomy or craniotomy. Rare causes of hemodynamic instability such as pelvic or femur fractures should be assessed first before going to aortography and repair of TAR [11]. If the patient has more immediately life-threatening injuries that require urgent intervention, or if the patient is a poor operative candidate because of comorbidities or age, the repair of TAR may be delayed. However, we recently found that urgent thoracotomy is mandatory in salvaging unstable patients with penetrating thoracic trauma, without evidence of injury to cardiac, aortic or other major vascular structures [12]. To determine the optimal time for surgical repair, medical treatment or stenting is dependent on many factors, particularly age, comorbidities, associated injuries and hemodynamic stability. In cases with delayed surgical intervention, it is extremely important to control blood pressure with beta-blockers or nitroprusside [13], but it is not easy at all to maintain an optimal blood pressure (not too high and not too low) in such patients who mostly are in hypovolemic shock. Furthermore, minimal invasive therapy is an evolving technology in the management of TAR. Since the publication of the first report describing the initial experience with endovascular stent-grafting (ESG) for abdominal aortic aneurysms in 1991, a number of cases with TAR have been treated and showed successful outcome [14]. By sealing the rupture initially with ESG hypotensive therapy is not necessary following insertion of stents which may act as a bridging therapy for patients with TAR waiting for a definitive surgical repair. On the other hand, ESG has serious complications such as endoleakage and migration and is not easily available in appropriate sizes. We have not tried this feasible therapy in the present study. However, prompt surgical repair of the TAR is the best approach [3]. There is considerable controversy surrounding the details of techniques of aortic repair. These techniques include both primary repair and placement of a prosthetic graft. In our study, direct suture was performed only in one patient and the ischemic time was 13 min. Many surgeons support the clamp and sew technique because it is expeditious, does not require bypass, and avoids complications associated with cannulation, bypass, and heparinization. However, a prospective multicenter trial [3] of TAR involving 50 busy trauma centers in North America has shown a mortality rate of 34% and a paraplegia rate of 10%. The mortality rate was not affected by the method of repair. This trial reported that bypass techniques that provide distal aortic perfusion produce significantly lowered paraplegia rates (4.5%) compared with the clamp and sew technique (16.4%). This is supported by a recent study [15]. Such a beneficial effect was clearly seen in our series where paraplegia was avoided. We, like others [3,5,15], recommend that repair of TAR surgically is best accomplished with some method of distal perfusion, and find that left heart bypass is an excellent method to prevent paraplegia in the management of patients with TAR. Despite our limited experience, which is characteristic for Scandinavian and European countries, our results were satisfactory.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
References
 
ICVTS on-line discussion

Author: Dr. Kenneth Mattox, Chief of Surgery, Ben Taub General Hospital, Surgery, One Baylor Plaza, Houston, Texas 77030, USA

Date: 04-Dec-2002 18:41

Message: Injury to the heart and great vessels is not limited to countries with interpersonal violence. As demonstrated by this paper, standardized and comparable results can be achieved through general agreement on standards of practice among the surgeons of the world (would that politics would be as standardizable). Of note in this article is a departure from the use of the thoracic CT scan as an initial screening and even diagnostic tool for thoracic aortic injury in many centers. These authors conform to this commentator's opinion that the CT scan does not alter decision making, but in most cases, merely leads to additional testing, at increased costs and time. In the future, increasing delay in operative therapy will be applied to "stable" patients with thoracic aortic injury and there will be increasing utility for intravascular stented grafts.

Response

Author: Moheb Rashid, Copenhagen University Hospital "Rigshospitalet", Cardiothoracic Surgery, Hagforsgatan 71, Gothenburg, 416 75, Sweden

Date: 12-Jan-2003 14:47

Message: Thank you very much for your interest in our study and we are pleased with your positive and kind comments. As you mentioned, CT scan does not alter decision making in patients with trauma to the thoracic aorta, this is true even in this part of the world, which enjoys less violence when compared with Texas. Recently, we have already started to transfer our ‘stable’ patients with suspected thoracic aortic injury to the catheterization laboratory equipped with endovascular stented grafts, restricted to some major university hospitals in Scandinavian countries.

Author: Professor Angelo Pierangeli, University of Bologna, Cardiovascular Surgery, Policlinico S.Orsola, Via Massarenti, 9, Bologna, 40138, Italy

Date: 16-Jan-2003 12:41

Message: In the present paper the authors describe their experience in traumatic lesions of the heart and the thoracic aorta, the presentation of the heart lesions is exhaustive. They reported a very limited experience in traumatic aorta treatment. In my opinion, their conclusions about management of these types of lesions are correct. I disagree with their diagnostic approach. The statement that angiography is a very sensitive, specific and accurate test is not supported by recent literature. Spiral CT and also MRI are much more sensitive than angiography (100% HCT and MRI vs 80-90% of angiography) in identifying TAR. In particular, HCT provides a comprehensive evaluation of polytrauma and should be considered the method of choice in TAR. Moreover, the angiography can increase the risks of fatal complications.

doi:10.1016/S1569-9293(02)00099-3


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 

  1. Breasted JH. The Edwin Smith surgical Papyrus. Chicago, IL: University of Chicago Press; 1930. p. 369
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  5. Von Oppell UO, Dunne TT, De Groot MK, Zilla P. Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg. 1994;58:585–593[Abstract]
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  8. Rashid MA, Örtenwall P, Wikström T. Cardiovascular injuries associated with sternal fractures. Eur J Surg. 2001;167:243–248[Medline]
  9. Nagy KK, Krosner SM, Roberts RR, Joseph KT, Smith RF, Barret J. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. World J Surg. 2001;25:108–111[CrossRef][Medline]
  10. Sturm JT, Hankins DG, Young G. Thoracic aortography following blunt chest trauma. Am J Emerg Med. 1990;8:92–96[CrossRef][Medline]
  11. Richardson JD, Wilson ME, Miller FB. The widened mediastinum: diagnostic and therapeutic priorities. Ann Thorac Surg. 1990;211:731–737
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  13. Fabian TC, Davis KA, Gavant ML, Croce MA, Melton SM, Patton JH Jr., Haan CK, Weiman DS, Pate JW. Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg. 1998;227:666–677[CrossRef][Medline]
  14. Lachat M, Pfammatter T, Witzke H, Bernard E, Wolfensberger U, Kunzli A, Turina M. Acute traumatic aortic rupture: early stent-graft repair. Eur J Cardiothorac Surg. 2002;21:959–963[Abstract/Free Full Text]
  15. Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS. Traumatic rupture of the thoracic aorta: cohort study and systematic review. J Vasc Surg. 2001;34:1029–1034[Medline]



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