Simultaneous penetrating wounds of the myocardium and aorta caused by firearms: surgical treatment.

Abstract

The frequency of trauma and penetrating wounds of the heart and the great intrathoracic vessels is continuously increasing. In peacetime heart wounds constitute about 3% of all penetrating wounds of the chest. About 40% of patients with penetrating wounds of the heart reach hospital alive. If these patients undergo an immediate pericardiocentesis and operation they have an 80-90% chance of survival. In a study of cases of penetrating gunshot wounds of the heart and aorta 31 patients died immediately while five survived for at least 30 minutes (Parmley et al, 1958).We present a case of simultaneous penetrating gunshot wounds of the myocardium and thoracic aorta when the patient survived more than 30 minutes and was successfully treated surgically. Repeated assessment during the four years since the injury has not shown any late complications. Case reportA white 52-year-old man was brought to the emergency room with a gunshot wound. The entry point of the projectile was in the left fourth intercostal space on the midclavicular line. The point of entry into the chest and the severity of the state of haemorrhagic shock led us to suspect a lesion of the heart or the aorta. A preoperative radiographic examination of the chest showed an increased heart shadow and mediastinal widening, a haemothorax, and the presence of a projectile in the left paracardiac region adjacent to the vertebral column. The arterial blood pressure was 60 mmHg during continuous blood transfusion and the central venous pressure 30 cmH2O. An electrocardiogram showed an alteration of ventricular repolarisation with notable raising of the S-T segment, and bradycardia.An emergency thoracotomy was performed through an incision in the fifth left intercostal space. Initial inspection of the thoracic cavity showed a haemothorax, haemomediastinum, and haemopericardium. By opening the pericardium, which contained 400 cc of blood, we could see two lesions of the myocardium -one on the anterior wall of the right ventricle near the anterior descending branch of the left coronary artery and the other a few centimetres from the apex of the left ventricle (fig 1). The greatest loss of blood was from the wound of the right ventricle. Digital Further inspection of the thoracic cavity led to the discovery of a large periaortic haematoma caused by two perforations of the thoracic aorta, one anteriorlI and one posteriorly at the level of the inferior pulmonary vein. Because of the impossibility of performing left heart bypass advantage was taken of the degree of hypothermia (34°C) and hypovolaemic hypotension (60 mmHg) of the patient. The aorta was totally clamped just above the wounds allowing direct 819 on 7 May 2018 by guest. Protected by copyright.