Table 1 Overview of the papers on penetrating cardiac injury from 1997 to 2012

[2] Asensio et al. (1998), J Trauma, USA. Prospective evaluation

2-year prospective evaluation of 105 penetrating cardiac injuries

65% GSW (survival 16%), 35% SW (survival 65%). EDT in 76 pts with 10 survivors (16%)

Presence of cardiac tamponade and the anatomical site did not predict outcome, presence of sinus rythm when the pericardium was opened did

[6] Baker et al. (1998), Arch Surg, USA. Retrospective study + review

106 pts with penetrating heart injury (1989–1995): 60 GSW, 46 SW, 55% overall survival.

6 patients on CPB (4 gunshots, 2 stabs, only 2 GSW survived)

Few survivors due to long time from injury to CPB. Those who were resuscitated >5 min prehospitally had a very poor outcome. SR at admission- good prognostic sign. CPB no good to reverse outbled situation/profound shock, but necessary to repair multichamber injuries/large injuries

[7] Bar et al. (2009), Ind J Thorac Cardiovasc Surg, Israel. Retrospective study

14 pts with penetrating cardiac wound requiring operation (1999–2006) (9 SW, 2 GSW and 2 schrapnel injuries, 1 multipl trauma)

4 sternotomies, 10 anterolat thoracotomies (8 with sternum transsection). 5LV, 6RV, 3RA injuries - all single chamber injuries, no combined.

No CPB, 100% survival, all discharged

Mean interval from injury to surgery 37 min

[8] Barbosa et al. (2011), Interact Cardiovasc Thorac Surg, Argentina. Case report

18 yr male, SW in 4th ic space in the left midclavicular line

Left thoracotomy, suture of right ventricular wound at admittance

Developed pneumonia/lung edema postop, after 30 days AVR for penetrated aortic valve and closure of shunt (RV -> aorta)

[9] Bowley et al. (2002), Ann Thorac Surg, South Africa. Case report

24 yr male, multiple stab wounds

No vital signs, PEA, at EDT: tamponade. 2 cm LV wound with LAD transsection, transsected PDA on the opposite side (RV)

Initially Foley catheter in the wound, mattress sutures, LAD ligation, PDA ligation. VF, hypotension: OPCAB with right gastroepiploic artery . Died of respiratory complications due to Brown-Sèquard lesion (another stab injury to the spinal cord)

[10] Burack et al. (2007), Ann Thorac Surg, USA. Retrospective study

207 pts with mediastinal penetrating trauma 1997–2003, 72 (35%) unstable.

72 unstabel pts, 15% had cardiac injury with 18% survival when explored in ED and 71% when reached OR

With penetrating mediastinal trauma the mortality is 85% when moribund at arrival and 55% when unstable (overall data, not injury specific)

[11] Carr et al. (2011), J Trauma, USA. Retrospective study

2000-2009 penetrating cardiac injuries, both GSW and SW

28 SW with 17 survivors (61%), no information about anatomical site

Functional outcome (5yrs) after: if coronary arteries were not involved - good chance to normal cardiac function at follow up.

[12] Chughtai et al. (2002), Can J Surg, Canada. Review + case report

Cases of 9 pts, 8 managed with CPB in trauma setting from 1992-1998

Only 2 pts of the presented had a sole cardiac injury (LV + coronary artery, RA + intrapericardial vena cava)

The patient with LV and coronary artey injury died (no CPB), the other patient survived without sequele

[3] Clarke et al. (2011), J Thorac Cardiovasc Surg, South Africa. Retrospective study

All patients with penetrating cardiac injury requiring operation from 2006-2009

Of 1062 stab wounds, 104 were operated, 76 had cardiac injury, overall mortality 10%. Approx 50% median sternotomy, 50% left thoracotomy

When data put together with mortuary data: mortality of 30% for SW (in the mortuary cohort of 548 patients with SW, 38% had penetrating cardiac injury). Less than 25% with penetrating cardiac injury reach hospital alive, of these ca 90% survive.

Mostly SW, also mortuary data analyzed. The center has no availability for CPB.

[13] Claassen et al. (2007), J Trauma, USA. Case report

2 male pts : 21 yr and 27 yr

Pas 1: SW in 5th right ic space (axilla) (+ in abdomen), 400ml on chest tube + knife blade in thorax: laceration of right ventricular outflow tract (sutured) + lung resection

Pas 2: SW in left supraclav midline. Tamponade at FAST: pericardial drainage, thereafter stable. Sternotomy after transfer, laceration of the pulmonary outflow tract, sutured, further repaire of aortopulmonary shunt (thrill + TEE)

Think outside the box: SW outside the precordium

[14] Comoglio et al. (2010), Int J Emerg Med, Italy. Case report

75 yr male with chest pain and syncope, had been working with a nailgun

Stable, underwent CT where the nailgun nail was found imbedded in the left ventricular wall. Removed through median sternotomy, suture without CPB

The pt underwent formal coronary angiography to rule out underlying coronary disease

[15] Desai et al. (2008), J Thorac Cardiovasc Surg, Canada. Brief communication

22 yr male, single SW in the left chest

Severe shock, loss of vital signs in the ED. EDT, ROSC after opening of pericardium. Tamponde + through-and-through laceration of the RV, stapled and transferred to OR

CPB, staples had occluded the PDA, the wound in close proximity. Staples removed, wound sutured. Intraoperative fluorescence coronary angiography showed widely patent PDA

[16] Fedalen et al. (2001), J Trauma, USA. Case report

30 yr male, isolated SW to left anterior chest wall

Tension pneumothorax, hypotension, cardiac tamponade. Transfer to OR

Median sternotomy, proximal laceration of LAD with posterior wall of the vessel intact. OPCAB with SVG, intraluminal shunt. Laceration used as anastomotic site. Discharge at postop day 8

[17] Fulton et al. (1997), Ann Thorac Surg, South Africa. Case report

61 yr male, a single SW in right 2nd ic space parasternally. History of right-sided empyema 18 yrs ago treated by thoracotomy and decortication

Stable, enlargened mediastinum at chest X-ray. Arcography showed laceration to innominate artery, left common carotid artery and left subclavian artery. Distal cannulation, repair in deep hypothermic arrest

Uneventful postoperatively, discharge at day 10

[18] Hibino et al. (2003), Journal of Cardiac Surgery, Japan. Case report

39 yr male, SW anterior chest wall, suicide attempt.

Median sternotomy at OR. Injury of the right ventricular outflow tract, repair without CPB

2 yr after aorto-right ventricular fistula (dyspnea), repair with patch and AVR. The authors suggest long term follow-up to detect unindentified lesions

[19] Ito et al. (2009), Gen Thorac Cardiovasc Surg, Japan. Case report

51 yr male, SW in left 5th ic space with the ice pick still in place, suicidal attempt

Ice pick was moving synchronously with heart beat, echo showed tip in right ventricle, cardiac tamponade

CPB, mattress stich. Heart murmur day 12, 5mm ventricular septal defect detected. No surgery, follow up

[20] Jodati et al. (2011), Interact Cardiovasc Thorac Surg, Iran. Case report

24 yr construction worker, shortness of breath and palpitations, unaware of the pneumatic nailgun injury

Nail through RV outflow tract, interventricular septum, through the mitral valve at TEE and CT.

Median sternotomy, CPB. Entry point on RV, nail tip barely visible, not exit wound after LA was opened. Nail removed, anterior leaflet of mitral valve repaired. Discharge at postop day 5

[21] Kang et al. (2009), Injury, New Zealand/Canada. Review

Review about causes of penetrating cardiac injury, pathophysiology, sequelae, initial and operative management

Hihglighted key points for every section, outlining of prognostic factors

Few other conditions in medicine are as lethal; death occurs from cardiac tamponade or exsanguination; the greatest danger is missing the dgn; resuscitation is of limited value; immediate operative intervention is the only meaningful treatment

[22] Karin et al. (2001), Eur J Emerg Med, Israel. Case report and literature review

1. 29 yr male with single SW in left chest. 2. 35 yr male, stabbed in left lower thorax

1. Cardiac tamponade, ED thoracotomy: SW in the LV transsecting LAD (ligated, sutured). CPB with SVG in OR 2. Hemopneumothorax, respiratory distress, chest tubes. FAST: tamponade. Left thoracotmy at OR, distal LAD transsection, ligated.

Both had normal echocardiographies postoperatively and were discharged respectively 10th and 7th postop day

[23] Kurimoto et al. (2007), Surgery today, Japan. Case report

57 yr male, SW in 5th ic space parasternally, suicide attempt

Arrest prehospitally, EDT at admission + pericardiotomy, further percutaneous CPB + repair at ED. 3 cm left ventricular wound near coronary artery

Postop encephalopathy, 3 yrs afterwards at rehabilitation home

[24] Lau et al. (2008), Singapore Med J. Case report

31 yr male, 2 SW: in the left 4th ic space and in the right 2nd ic space

Pulseless with PEA, EDT, SW in the RV, internal cardiac massage to ROSC, transfer to the OR. Suture of the laceration

Discharged to further rehabilitation due to hypoxic encephalopathy

[4] Molina et al. (2008), Interact Cardiovasc Thorac Surg, USA. Retrospective study

237 pts (2000–2006) with EDT for penetrating injury, of these 94 with penetrating cardiac injury

GSW 87%, SW 13%, overall survival 8% (5% for GSW, 33% for SW)

None of the patients who reached OR needed CPB. Predictors of survival: sinus rythm, signs of life at ED, SW vs GSW, transport by police, higher GCS

Mostly GSW -very poor outcome

[25] Moore et al. (2007), Am Surg, USA. Case report

16 yr male, multiple stab wounds

Tachycardia and hypotension, left hemothorax. FAST: pericardial and infraabdominal fluid. LAD injury (ligation), RV (suture).

OPCAB (SVG) due to evolving large anteroseptal MI. Abdominal packing. Discharge postop day 17.

[26] Nwiloh et al. (2010), Ann Thorac Surg, USA/Nigeria. Case report

11 yr boy, arrow in the 4th ic space

Pt admitted 3 days after hunting with arrow in the midline. Attempted retracted at local hospital, referred to the visiting cardiothoracic team from USA. TTE: arrow through right ventricle, ventricular septal shunt

CPB, retraction of the arrow and suture of the RV. Shunt was insignificant, not repaired

[27] O’Connor et al. (2009), J R Army Med Corps, USA. Review

History, demographics and outcome, repair techniques, special occasions etc.

Refer to iv adenosin infusion for temporary arrest to facilitate the repair

[28] Parra et al. (2010), J Thorac Cardiovasc Surg, USA. Case report

81 yr male struck by a stingray in his left chest

CT: left pneumothorax, foreign body through mediastinum. Left anterior thoracotomy at the OR, the barb was found imbedded in the heart, the entry was repaired and pt transferred to a cardiac center

At cardiac center: CPB, barb through both right and left ventricles. RA was accessed and the barb pulled out in an antegrade fashion. Ventricular septal and RV defects closed with pledgeted sutures. Discharge 60 days postop

Splenectomy due to hemorrhage postop day 1 (unidentified injury, the pt fell when attacked by the sting ray)

[29] Seamon et al. (2009), J Trauma, USA. Retrospective study

283 pts with cardiac or great vessel penetrating injury requiring EDT (2000–2007)

88% GSW (survival 2,8%), 12% SW (survival 24,2%)

Predictors of survival in multivariate analysis: GSW and GCS

Multiple GSW almost unsalvagable

[30] Sugiyama et al. (2011), Ann Thorac Surg, USA. Case report

20 yr male, SW in left chest (nipple level)

Cardiac arrest at ED, left anterior thoracotomy, suture of right ventricle

Postop instable, 7. day - 1,9 cm septal defect with left to right shunt (3,7-1), ARDS etc., shunt=VSD repaired 2 mnths afterwards

[5] Tang et al. (2011), Arch Surg, USA. Retrospective study

406 pts with penetrating cardiac injury from 2000-2010

74% SW, 26% GSW. Overall survival 27%.

Focusses on postdischarge complications, 17% had an abnormal echocardiogram at follow-up; all managed conservatively

[31] Tasdemir et al. (2011), Acta Cardiol, Turkey. Case report

19 yr male, SW left chest

Presented in shock, tamponade andcomplete bilat visual loss. SW of LV with LAD injury,

CPB, SV graft to LAD, visus gradually regained

[32] Toda et al. (2007), Interact Cardiovasc Thor Surg, Japan. Case report

50 yr male, 3 SW by 30 cm sashimi knife, (Neck, 4th ic space, right upper quadrant of abdomen), suicidal attempt

Hypotensive, FAST negative, CT showed pneumopericardium and left hemothorax

Median sternotomy, RV laceration, repair by pledgeted sutures. LV laceration near posterolateral branch of CX, without bleeding, covered with TachoComb.

[33] Topal et al. (2010), J Trauma, Turkey. Retrospective study

Penetrating cardiac injury (57 SW, 4 GSW), 2002-2009

53 left thoracotomies, 4 median sternotomies. 2 LAD injuries, ligated. Total mortality 15% (isolated RV −11%, isolated LV 31% (mixed SW and GSW).

95% injury in 1 chamber. Focusses on predictors of outcome: > mortality when uncouncious, BP<50, low Hct, Na, temp and PH. Patients pronounced “dead on arrival” were not assessed in this study.

[34] Topaloglu et al. (2006), Tex Heart Inst J, Turkey. Case report

19 yr male, SW with skrewdriver in 5th left ic space

Dyspnea and hypotension, 1500ml chest tube output. Left anterior thoracotomy at OR, RV wound repair.

1 week later a cardiac murmur occurred, transfer to a cardiac center, TTE: perforation of membranous septum and anterior leaflet of the mitral valve. Median sternotomy, CPB, LA access: pericardial patchrepair of the leaflet, suture of the septal defect through RA. Discharged postop day 5.

[35] Topcuoglu et al. (2009), Thorac Cardiovasc Surg, Turkey. Case report

14 yr male, SW in right 6th icr paravertebrally, stable with knife in place

Right posterolat thoracotomy (knife in situ), at removal bleeding from atrio- inferiocaval junction

Repair on CPB, discharged on 7th postop day

[36] Gwely et al. (2010), Thorac Cardiovasc Surg, Egypt. Retrospective study

73 pts operated for cardiac SW (1998–2008)

Unstable 35%, 20% cardiac arrest prior to EDT. Mortality 23%

Poor prognosis: cardiopulmonary resuscitation (mortality rate 68%), EDT (67%) and shock (50%) on admission

Dead on arrival excluded