D. Smego1, N. Djordjevic1, K. Karlson2, K. Yin2, N. Dobrilovic1,2 1Rush University Medical Center,Cardiovascular And Thoracic Surgery,Chicago, IL, USA 2Boston University,Cardiovascular And Thoracic Surgery,Boston, MA, USA
Introduction:
Cardiac and intrathoracic vascular missile injuries (CIVMI) are highly lethal. Patients arriving to a medical facility are most commonly hemodynamically compromised and/or in extremis. Rarely, are these patients stable without signs of major compromise. In this report, we examine the role of delayed treatment for stable patients with CIVMI.
Methods:
This study was conducted as a retrospective review at a major level-1 trauma center. All patients suffering CIVMI were examined. Hemodynamically stable patients that did not require immediate operative intervention were selected for inclusion. Treatment strategies, operative findings, and corresponding outcomes are reported for this group of patients that underwent delayed operative intervention.
Results:
Ten patients fit inclusion criteria. Mean age was 22 years (range of 13-43). Various imaging modalities documented a retained cardiac missile (RCM) in all 10 patients. Transthoracic echocardiography and chest computed tomography angiogram were the most commonly performed diagnostic studies. Each was performed in 9/10 (90%) study patients. Transesophageal echocardiography was performed in 3/10 (30%) patients. Operative intervention occurred in 9/10 (90%) patients; 1/10 (10%) refused. The duration from time of injury to time of operation was a mean of 4.7 days, median 2 days. Operative findings included a bullet lodged in the ventricular septum (n=3), free floating bullet in the pericardial space with no associated cardiac wounds except for a pericardial entrance site (n=2), brachiocephalic vein injury (n=1), left common carotid / left subclavian vein injury (n=1), ascending aortic pseudoaneurysm (n=1), infracardiac, supradiaphragmatic inferior vena cava injury with bullet migration to the left main pulmonary artery (n=1). The single patient refusing surgery was diagnosed with a left ventricle to right atrium communication with significant heart failure. Cardiopulmonary bypass was required in 4/9 (44%) of operative patients and deep hypothermic circulatory arrest in 1/9 (11%). A RCM was retrieved in all (9/9) operative cases. There were no mortalities.
Conclusion:
Stable patients with retained cardiac or intrathoracic vascular missile injuries can be safely managed in delayed fashion. Such a delayed treatment strategy may benefit the trauma patient suffering from multisystem injury and may be viewed as analogous to the strategy of selective, delayed intervention adopted in the treatment of traumatic aortic disruption.