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Clinical Procedures > Cardiothoracic Procedures
Ventricular Repair
Article Last Updated: Jul 11, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: David R Roth, MD, Staff Physician, Jacobi/Montefiore Emergency Medicine Residency Program, Bronx, NY
David R Roth is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Coauthor(s):
Hong Keun Choi, MD, MPH, Assistant Professor, Associate Residency Site Director, Montefiore Medical Center, Bronx, NY
Editors: Andrew K Chang, MD, Department of Emergency Medicine, Albert Einstein College of Medicine, Assistant Professor, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, Pharmacy Editor, University of Nebraska Medical Center College of Pharmacy, eMedicine.com, Inc; Luis Michael Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA, Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Department of Emergency Medicine, David Geffen School of Medicine, UCLA Medical Center; Rick Kulkarni, MD, Assistant Professor of Medicine, Department of Emergency Medicine, David Geffen UCLA School of Medicine; Director of Informatics, UCLA/Olive View-UCLA Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
cardiorrhaphy, thoracotomy, penetrating chest trauma, cardiac tamponade, trauma resuscitation, laceration repair, ventricular repair, cardiac repair, emergency cardiac repair, emergent ventricular repair, penetrating cardiac trauma, ED ventricular repair, blunt chest trauma
Ventricular repair, or cardiorrhaphy, has long been one of the most dramatic and lifesaving procedures performed in the emergency department (ED). Its use in penetrating cardiac injuries was first proposed by Block after he performed cardiac laceration repair in canines in 1882.1 The first successful human cardiorrhaphy was performed by German physician Rehn in 1896 to repair a right ventricular injury sustained during a fencing match.2 The first successful cardiorrhaphy in the United States was performed by Hill in 1902; he operated on a teenage stabbing victim on a kitchen table in Montgomery, Alabama.3 This began the accepted practice of emergent cardiac repair in patients who sustain life-threatening penetrating trauma to the heart.
The science of surgical resuscitation has advanced tremendously since Rehn performed the first human cardiorrhaphy. The popularity of this procedure has waxed and waned because of changing surgical techniques and differing analyses of patient outcome data. Currently, the indications for emergent thoracotomy with or without cardiorrhaphy include the following:
- Cardiac arrest in patients with penetrating chest trauma for whom signs of life (ie, palpable pulse, pupillary response, spontaneous ventilatory effort) were present at the scene or in the emergency department4
- Worsening hypotension or evidence of cardiac tamponade in the setting of blunt or penetrating trauma
- Instability in patient who presents with the above indications (ie, transfer to an operating room delays necessary immediate intervention)
- Patient is clinically stable
- Blunt trauma in patients with no signs of life upon arrival5
- Patient with signs of prolonged death (eg, rigor mortis, livor mortis)
- Patient whose life is unsalvageable (eg, decapitation)
Always attend to the ABCs, particularly in trauma patients. Ideally, intubate patients prior to thoracotomy or cardiorrhaphy. If that is not possible, intubate during the procedure to secure the airway. Administer general anesthesia by way of rapid sequence intubation (RSI) protocols and postintubation sedation, analgesia, or paralysis. Local anesthesia is not feasible and may cause life-threatening arrhythmias because the maximum dose of lidocaine may be exceeded for a thoracotomy incision. Pay close attention to signs of pain or agitation in the intubated patient (eg, tachycardia, overbreathing the ventilator, suboptimum paralysis). Choose appropriate sedative and neuromuscular blockading agents to maintain both cardiovascular output and effective anesthesia.
Thoracotomy tray should include the following:
- Sterile prep
- Scalpel (#10)
- Mayo or Metzenbaum scissors
- Rib spreader
- Tissue forceps, 2
- Satinsky vascular clamps, 2
- Pean and Crile hemostats
- Lebsche knife
- Hegar needle holders, 3
- Nylon suture (3-0) on a curved needle
- Teflon pledgets
- Suture scissors
- Surgical stapler
- Sterile towels
- Sponges
- Foley catheter
- Chest tube
- Towel clips
- Place the patient in a supine position with the left anterior chest wall exposed.
- Prepare the left anterior chest wall with povidone-iodine (Betadine) and sterile towels.
- Make an incision in either the fourth or fifth intercostal space. In men, this location corresponds to the area inferior to the nipple; in women, the inframammary fold can be used as a landmark. The breast may need to be retracted in women in order to expose this area. The incision should begin just lateral to the sternum on the left and continue to the midaxillary line. Take care to confine this incision to the inferior border of the intercostal space throughout its course. This ensures wide exposure with the rib spreader through a single intercostal space and decreases the possibility of injuring the neurovascular bundle, which courses over the inferior border of the upper rib. Placing a rolled towel or sheet under the patient’s left side and elevating the left arm over the head can augment exposure and ensure a wide enough incision.
Primary incision in the fourth or fifth intercostal space.
- The initial incision should be deep enough to cut through the pectoralis major and serratus muscles. The intercostal muscles can be bluntly dissected with the end of the scalpel or scissors. Once the pleura is exposed, make an initial opening with the scalpel. Use the scissors to open the pleura along its length from the scalpel opening; try to avoid further injury to underlying intrathoracic structures.
Open the pleura with scissors.
- Insert the rib spreader in its closed position through the intercostal incision. Crank the handle to separate the blades and open the chest. Open the chest widely enough to easily access the mediastinum.
Chest opened with rib spreader.
- Identify the pericardium and make a small initial opening; be sure to avoid the phrenic nerve, which runs vertically along the lateral border. If cardiac tamponade is present, a gush of blood ensues after the initial opening is made. Use the fingers to tear the pericardium longitudinally, opening it along its length. Remove any clots or remaining blood within the pericardium.
Initial opening of the pericardium with the scalpel.
- Inspect the heart for obvious lacerations and quickly identify the coronary arteries. Current data suggest that the incidence of chamber laceration in penetrating cardiac injury is as follows: 40% right ventricle (RV), 40% left ventricle (LV), 24% right atrium (RA), and 3% left atrium (LA).6 Once the laceration is isolated, several methods exist for temporary hemostasis. If the laceration is small enough, a finger may be placed at the site of laceration while suture is prepared. Alternatively, a Foley catheter may be placed through the wound and the balloon inflated. Pull back on the catheter until resistance is met to seal the wound. Medications may be administered through the Foley catheter into the intracardiac space.
Locate the laceration.
- To begin the cardiorrhaphy procedure, thread the nylon suture through the Teflon pledget and place a horizontal mattress suture across the laceration.
Suture threading.
Thread the suture through another Teflon pledget on the opposite wound edge and complete the mattress stitch.
Completed mattress stitch.
The pledgets prevent further injury to an already friable myocardium. Repeat the suture step until the laceration is sufficiently approximated. Be mindful of the coronary arteries, as a suture placed into or over one of these may have disastrous consequences.7,8,9
Sufficiently approximated laceration.
In cardiorrhaphy, surgical staples are an excellent alternative to suture with pledgets. Both Bowman10 and Mayrose11 have indicated that the use of surgical staples reduces time to wound closure and has similar repair integrity. This method also reduces the risk of exposure to contaminated needles in the setting of ED thoracotomy. These studies suggest that stapling a beating heart is faster and safer than suturing with pledgets.
- Penetrating trauma to the chest in an unstable patient is an indication for thoracotomy and cardiorrhaphy.
- The ventricles are involved in 80% of penetrating cardiac wounds.
- Once a cardiac wound is identified, obtain hemostasis quickly with a finger or Foley catheter while closure materials are prepared.
- Surgical staples may be a faster and safer cardiorrhaphy closure method than suture with pledgets.
- Infection, including thoracic sepsis, empyema, and pneumonia12
- Injury to underlying intrathoracic structures, including, but not limited to, the lung, heart, great vessels, coronary arteries, thoracic duct (chylothorax), esophagus, and phrenic nerve
- Uncontrolled hemorrhage9
- Postpericardiectomy syndrome (fever, chest pain, pericardial effusion, pericardial rub, elevated ST segments on ECG)13
- Dysrhythmias
- Exposure to infectious blood and tissue (eg, HIV, hepatitis B, hepatitis C) by the ED physician and ancillary staff
American College of Emergency Physicians
1125 Executive Cir
Irving TX 75038-2522
800-798-1822
American Association for Thoracic Surgery
900 Cummings Ctr, Ste 221-U
Beverly MA 01915
978-927-8330
eMedicine.com, Inc: Penetrating Chest Trauma
eMedicine.com, Inc: Abdominal Trauma, Penetrating
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Primary incision in the fourth or fifth intercostal space. |
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Initial opening of the pericardium with the scalpel. |
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- Beck CS. Wounds of the Heart. Arch Surg. 1926;13:205.
- Rehn L. Ueber Penetrirende Herzuden und Herznaht. Arch Klin Chir. 1897;55:315.
- Hill LL. A report of a case of successful suturing of the heart, and a table of 37 other cases of suturing by different operations at various terminations, and the conclusions drawn. Med Rec. 1902;846.
- WorkingGroup, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. Practice management guidelines for emergency department thoracotomy. J Am Coll Surg. Sep 2001;193(3):303-9. [Medline].
- Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. Mar 2000;190(3):288-98. [Medline].
- Wall MJ Jr, Mattox KL, Chen CD, Baldwin JC. Acute management of complex cardiac injuries. J Trauma. May 1997;42(5):905-12. [Medline].
- Biffl WL, Moore EE, Johnson JL. Emergency Department Thoracotomy. In: Moore EE, Feliciano DV, Mattox KL. Trauma. 5th ed. New York, NY: McGraw-Hill Incorporated; 2004:242-244.
- Jackimyczyk KC, Ordog GJ. Thoracotomy. In: Rosen. Atlas of Emergency Procedures. Philadelphia, PA: Elsevier - Health Sciences Division; 2001:46-49.
- Ordog GJ. Cardiorrhaphy. In: Rosen. Atlas of Emergency Procedures. Philadelphia, PA: Elsevier - Health Sciences Division; 2001:54-55.
- Bowman MR, King RM. Comparison of staples and sutures for cardiorrhaphy in traumatic puncture wounds of the heart. J Emerg Med. Sep-Oct 1996;14(5):615-8. [Medline].
- Mayrose J, Jehle DV, Moscati R, Lerner EB, Abrams BJ. Comparison of staples versus sutures in the repair of penetrating cardiac wounds. J Trauma. Mar 1999;46(3):441-3; discussion 443-4. [Medline].
- Bartlett RL. Resuscitative Thoracotomy. In: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia, PA: W.B. Saunders Co.; 1998:277-278.
- Ivatury RR. The Injured Heart. In: Moore EE, Mattox KL, Feliciano DV. Trauma. 4th ed. New York, NY: McGraw-Hill; 2000:551-555.
Ventricular Repair excerpt Article Last Updated: Jul 11, 2006
Topic originally published: Jul 11, 2006
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