Delayed Cardiac Rupture Induced by Traumatic Myocardial Infarction: Consequence of a 45-Magnum Blast Injury; A Comprehensive Case Review

Abstract

A penetrating chest trauma, a myocardial contusion or a myocardial infarction can lead to a cardiac rupture, which is linked to an extreme high death rate. Only few cases with delayed perforation of the myocardium have been reported in literature. We report about a penetrating gunshot injury, which led to a myocardial contusion with secondary delayed rupture of the left ventricle and the left inferior lobe of the lung. The leakage of the lesion in the left ventricle could be sealed sufficiently with fibrin-coated collagen fleeces after adapting stitches with Prolene 2-0. For additional stabilization of the vulnerable myocardium area, a bovine patch has been placed on the damaged ventricle. Fibrin fleeces are used successfully in cardiac surgery, as in our case, to seal the leakage of the lesion in the left ventricle. The implantation of a bovine patch in the pericardium could prevent a cardiac compartment syndrome with a fatal pericardial tamponade. To prohibit a thoracic compartment syndrome a modified Bogota bag could be sewed in for temporarily closure of the chest. In most cases penetrating cardiac injuries can be treated without heart-lung-machines. An immediate transfer to a cardio-surgical center is, due to the acute situation, not possible. If a surgeon with thoraco-surgical expertise is present a transfer is not absolutely necessary,

Thoracic compartment syndrome after penetrating heart and lung injury

“…Patients with a pericardial tamponade can stay hemodynamically stable for a longer time. Clinical symptoms vary or can be completely missing until the intrapericardial pressure exceeds the diastolic pressure, which leads to a circulatory collapse [ 3 ], [ 4 ], [ 5 ]. Because of that, penetrating thoracic traumata must be considered as “worst case scenarios” until the contrary is proven.…”

“…Aggressive diagnostics and therapy are required. The “time factor” plays an important role for prognosis [ 5 ], [ 6 ], [ 7 ], [ 8 ].…”

“…Most patients with this injury pattern die of a tension pneumothorax, for example, on the way to the hospital. They do not primarily die of a myocardial lesion [ 5 ].…”

“…In cases of an acute blood loss of 1,000 ml over the drainage or continuous blood loss of 200–300 ml over 3 hours, an emergency thoracotomy is necessary [ 5 ], [ 12 ], [ 13 ].…”

“…Standard access is the lateral thoracotomy, which allows the disconnection of the lung hilum (also for prevention of an air embolism), the pericardiotomy and the direct heart massage [ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 13 ], [ 16 ], [ 17 ]. The left lateral thoracotomy also allows the disconnection of the descending aorta over the diaphragm to improve the blood circulation of the coronary arteries retrogradely [ 4 ].…”