PENETRATING RIGHT VENTRICULAR PENETRATING RIGHT VENTRICULAR WOUND IN ASSOCIATION WITHWOUND IN ASSOCIATION WITH

INTERNAL MAMMARY AND BRACHIAL INTERNAL MAMMARY AND BRACHIAL ARTERY TRANSACTION:ARTERY TRANSACTION:

A CASE REPORTA CASE REPORTBy

Professor Abdulsalam Y Taha

Sulaimani Teaching HospitalSchool of Medicine

University of SulaimaniIraq

https://sulaimaniu.academia.edu/AbdulsalamTaha

INTRODUCTION

The incidence of penetrating cardiac injuries appears to be rising, presumably because of an increase in civilian violence.

In 1896, Dr. Ludwig Rehn of Frankfurt, Germany first successfully sutured a stab wound of the heart. It was a case of right ventricular wound. He wrote reporting the case: This proves the feasibility of cardiac suture repair without a doubt! I hope this will lead to more investigations regarding surgery of the heart. This may save many lives.) But for decades this operation remained an isolated historic achievement.

Certainly, stab wounds of the heart were common prior to 1896, but what held surgeons back? Perhaps it was the belief, held by authorities since antiquity, that cardiac wounds could not be healed.

Aristotle wrote: The heart alone of all the viscera can not withstand injury. This is expected because when the main so- urce of strength- the heart- is destroyed, no strength can be brought to other organs which depend on it.

In 1882, Block reported creating stab wounds in rabbits hearts and then repairing them. He suggested attempts in patients.

Billroth commented on Block s repair of rabbit heart wounds:

) A surgeon who tries to suture heart wounds deserves to lose the esteem of his colleagues(.

Stephen Paget )1896: Surgery of the Chest(: Surgery of the heart has probably reached the limits

set by nature to all surgery: no new method or discovery can overcome the natural difficulties that

attend a wound of the heart.(

Ten years after Rehn initial repair, he accumulated a series of 124 cases with a mortality of only 60%

quite a feat at that time.

George Fischer published a monograph in 1868that documented a 10% recovery rate in 452cases with heart wounds.

The report indicated that heart wounds did notnecessarily result in certain death.

Herein, a case of right ventricular woundassociated with laceration of left internal

mammary artery- LIMA- and brachial artery transaction is reported. The management of

the case is outlined with literature review.

•Informed consent of the patient is obtained to publish his images.

CASE HISTORY

CASE• R B• 35 year old man• 25th Sept. 2004• Three hours afterinjury. Two stab wounds:

Ant. chest & L arm. Chest wound: L 4th

i c space just lateralto sternum. Profusebleeding on leaning forwards. Pallor and shock. Bp= 80/60 mmHg PR= rapid and feeble. Heart sounds:

inaudible.

Chest: good air entry bilaterally.

Neck veins: distended. L upper limb:

Bleeding controlled by dressings. Ischaemic limb.

Normal-sized heart No haemo- or pneumothorax

R V repair: interrupted Dacron-buttressed mattress 2-0 silk sutures.

Lacerated LIMA:

Controlled by ligation.

Fasciotomy: viable tissues.

End to end repair of brachial artery.

DISCUSSION

The presented case has a combination of threepotentially fatal injuries. Penetrating cardiacinjury, LIMA laceration and transaction of brachialartery. Any of these injuries can kill the patient byexsanguinations. Laceration of LIMA is a common

associated injury.

The two life- threatening problems after cardiactrauma are tamponade and haemorrhage.

Tamponade develops rapidly as the normal pericardium can accommodate only 100 to 250 mlof blood.

Small wounds, such as those from a knife, oftenproduce tamponade because the laceration in thepericardium is small. Larger wounds, produced bybullets or larger knives, threaten immediate deathfrom exsanguinations as blood can be expelledthrough the pericardial laceration into the pleuralcavity.

Generally speaking, tamponade carries a betterprognosis than frank haemorrhage. The RV, which constitutes most of the anteriorportion of the heart, is the cardiac chamber mostfrequently injured.

The patient with penetrat ing cardiac injury shouldbe taken to the operation room as quickly as possible. As stated by Kirkl in and Barrat Boyes, nomore than 5 minutes need elapse between admission and the patients transfer to the operating table.

A median sternotomy is the preferred incision, as it provides ready access to all chambers of theheart.

In this case, the external bleeding arose from bothlacerated LIMA and ventricular wound. Cardiac tamponade resulted from clots sealing thepericardial defect.

The site of stab wound( left 4th inter-costal space)together with triad of hypotension, distended neckveins and inaudible heart sounds were highly indicative of tamponade.

Rapid transport of patient to operating room andurgent surgery were essential to save this patient.

The R coronary artery was fortunately not involvedby the wound.

The standard technique was used in repair.Air embolism was prevented by digital sealingof the wound.No sign of myocardial ischaemia occurred.

The lacerated LIMA was treated next to ventricular wound.

The peripheral arterial injury was the last to be considered in this patient whose life salvage took the priority over limb salvage.However, arterial repair was done as meticulously as we used to do in isolated arterial injuries. Fasciotomy was detrimental to his limb salvage.