Stable Penetrating Chest Trauma

Annotation for Point P

Sternotomy is the optimal approach to manage cardiac injuries. Splitting the pericardium anteriorly, up to the origin of the ascending aorta, and dividing laterally along the diaphragmatic reflection obtain maximal exposure. Pericardial retraction stiches will elevate the heart. If there are posterior wounds, gently packing a sponge along the diaphragmatic surface will elevate the posterior surface of the heart. Most cardiac injuries can be repaired with simple 3-0 mattress sutures using pledgets (pericardium is an easy substitute). If the injury is close to a major coronary artery, placing horizontal sutures deep to either side of the artery will reduce the chance of coronary occlusion.⁵² Direct injuries to the coronary artery can be repaired primarily with 6-0 or 7-0 sutures, usually in an interrupted fashion.As a rule, proximal left anterior descending coronary arteries require repair, while more distal injuries, right coronary, and/or circumflex injuries in the absence of obvious major cardiac compromise aremanaged by ligation.²⁴ If the patient is stable and has a critical coronary injury, such that it is evident that a major myocardial injury will result, repair with vein or internal mammary bypass has been reported.²⁴ This can be performed ‘‘on or off pump.’’ Injuries close to the coronary ostia or ascending aorta can be managed with primary repair using caval occlusion or mechanical circulatory support.^24,53 After procedure, a formal transesophageal echocardiogram should be performed to rule out septal or valve defects. Persistent evidence of myocardial ischemia should prompt coronary angiogramwhen possible to exclude rare coronary fistula or occlusions that might be amenable to stenting. Septal or valvular defects that are not associated with major hemodynamic compromise can be repaired when the patient is more stable.²⁴ Stable patients with major septal or valvular defects with no other major injuries can be evaluated by transesophageal echo and may undergo immediate repair.⁵⁴