The management of stab wounds to the heart with laceration of the left anterior descending coronary artery

Abstract

Penetrating cardiac injuries are an increasing cause of traumatic deaths in urban areas. The management of these injuries has undergone a transition from simple pericardiocentesis to cardiac ultrasound evaluation in the stable patient, and emergency thoracotomy and repair of myocardial wounds in the unstable patient in extremes. The incidence of traumatic coronary artery injury is not accurately known because not all victims are examined. With the improvement in emergency medical services, including speed of transportation of these patients, better resuscitation, and knowledgeable use of cardiac ultrasound or emergency room thoracotomy, more patients with coronary artery injuries will survive and reach the operating room. The operative management of the injured coronary artery is dependant on the location of the injury and whether there is myocardial dysfunction. Distal injuries with small myocardial infarction should be treated by ligation alone. Proximal injury and those injuries associate with larger area of ischaemia or infarction are best treated with coronary artery bypass. The role of cardiopulmonary bypass pump in these patients should be evaluated depending on the homodynamic stability of the patient. We present two cases of cardiac stab wounds with transection of the left anterior descending (LAD), which were successfully managed. A literature review regarding the management of combined cardiac and coronary artery injuries is also provided.

Cardiac surgery take-away kit

“…They are difficult to obtain in emergencies but can be life-saving. 3 In case 1, an intracoronary shunt was used to provide distal coronary flow while the CABG was performed. The transected LAD was difficult to repair and the anastomosis was performed distally, then the shunt was removed and the LAD ends were ligated.…”

Successful Management of a Stab Wound to the Left Ventricle

“…The Left Anterior descending artery, due to its accessible site, is the chief coronary artery associated with significant cardiac dysfunction when injured with Asensio and his colleagues reporting a mortality rate of 89% associated with coronary artery injury. 5,13 It is for these reasons juxta LAD artery and LV injuries are difficult to manage and may require cardiopulmonary bypass and grafts to LAD but in this case the injury was managed without going on the cardiopulmonary bypass.…”

“…A lot of cases presenting with injuries to the coronary arteries are young men, being a victim of violent social altercation. 13 Acute cardiopulmonary bypass is generally reserved for proximal coronary artery damage along with intractable cardiac failure. The Left Anterior descending artery, due to its accessible site, is the chief coronary artery associated with significant cardiac dysfunction when injured with Asensio and his colleagues reporting a mortality rate of 89% associated with coronary artery injury.…”

How to mend a broken heart: a major stab wound of the left ventricle

“…On the other hand, full heparisation might cause severe morbidity, and CPB might initiate consumptive coagulopathy and profound systemic inflammatory reaction [28]. Off pump cardiopulmonary bypass is an alternative when it comes to coronary artery lesions [16,22,25]. Establishing CPB in arrested patients or patients in deep haemorrhagic shock is not favourable for the outcome [6].…”