Successful surgical management of penetrating heart injury due to bomb explosion in a child
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《血管的通路杂志》
Bakoulev Scientific Center for Cardiovascular Surgery, 135, Roublevskoye shosse, Moscow, 125552, Russia
Abstract
Unusual penetrating injury of the heart in a 10-year-old child is described. The patient was admitted because of clinical symptoms of acute infection. The accurate diagnosis was put on echocardiography and computed tomography. After sternotomy, no evidence of previous heart injury was noted. A piece of metal from a terrorism-related bomb explosion was located within the free wall of the right ventricle. The urgent surgery led to full recovery of the child.
Key Words: Penetrating cardiac trauma
1. Introduction
Penetrating trauma of the heart for various reasons has been reported [1–4]. Recently, the incidence of heart injury, secondary to a terrorism bomb explosion, unfortunately, has increased. The aim of this presentation is to demonstrate the role of accurate preoperative imaging and emergent surgery in good outcome of this rare case.
2. Case report
A 10-year-old boy was admitted to our center with fever (40 °C), dyspnoea, anxiety, and hepatomegaly. Ten days previously during the opening ceremony of the new School Year in Beslan (September 1st) the school was invaded with this child, other children and their parents, by terrorists and managed to escape from the school building after bomb explosions. No further follow-up was performed after initial resuscitation at the regional hospital. On the 7th day the above claims have been mentioned. The X-ray showed a foreign body in the chest, superimposed on cardiac silhouette.
On physical examination of the chest, there was a 2 cm scar in the pectoral region to the left side of the sternum. He had no murmur on auscultation. The transthoracic echocardiography identified a piece of metal, located within the right ventricle (RV) (Fig. 1). Severe tricuspid insufficiency was detected with color flow Doppler. Computed tomography of the thorax confirmed diagnosis and suggested that the foreign body was situated in the free wall of the RV.
Due to the high temperature, clinical symptoms of acute infection and the patient's increasing anxiety, he was scheduled for emergent operation.
At median sternotomy, a hole in the pericardium 2 cm in diameter was found, but there was no evidence of previous heart injury. Intraoperative transesophageal echocardiography was made and location of the foreign body in the wall of the RV was confirmed. Cardiopulmonary bypass was established. Both vena cava were snared and the operation was performed on beating heart under moderate hypothermic cardiopulmonary bypass. The right atrium was opened. A piece of metal with a sharp margin (20x20x15 mm) was found within the free wall of the RV, immediately underneath the anterior leaflet of the tricuspid valve (Fig. 2). The anterior tricuspid leaflet was longitudinal ruptured. Large vegetation attached to the foreign body were seen. The metal was removed with extensive resection of the surrounding infected tissue. The hole, made in the free wall of the RV was repaired directly with a continuous suture. Five stitches repair of the anterior tricuspid leaflet was performed with a 5-0 polypropylene suture.
Postoperatively, the patient made a good recovery. Antibiotic administration was stopped on postoperative day 14. Postoperative two-dimensional echocardiogram revealed no regurgitation on the tricuspid valve. The patient was discharged in good condition.
3. Discussion
The first successful repair of a penetrating cardiac wound was reported by Rhen in 1897 [5]. This date has been suggested to be the starting point of the era of surgery on the heart.
Although patients with stab wounds of the heart usually survive when treatment is adequate, patients with missile wounds have far less successful results [6].
Our case could be interesting for the following:
First, a shrapnel penetrated the thorax and pericardium and rested within the right ventricle. However, during surgery we did not find evidence for hemorrhage.
Second, the child remained symptomatic after the injury until he presented 7 days later. The main symptoms of dyspnea and hepatomegaly were leaded to severe tricuspid regurgitation. Intra-operatively, the anterior tricuspid leaflet was longitudinal ruptured, but without damage to subvalvar structures. So, the valve was simply repaired by suturing the (cleft) with interrupted sutures of 5-0 polypropylene.
Finally, the child was transferred to the operating room in the first hour after admission to our center. At operation a foreign body with the surrounding tissues were removed and sent for culture. The patient received intravenous antibiotics (Maxipin + Rifampicin) immediately after the operation. This therapy was adapted to the germ found in the blood and tissue cultures (streptococcus). Antibiotic therapy was continued with Amoxicillin, Rifampicin and Metronidazol for two weeks. It was discounted after verification of the absence of clinical symptoms and normalization of the systemic parameters of inflammation (normal blood counts, negative blood culture and especially – test of Procalcitonin – 0.17 (norm up to 0.5). During the hospital period his temperature remained normal. An outpatient clinic was used for follow up 12 weeks after discharge. No recurrent or persistent evidence of infection has been revealed.
4. Conclusion
Early diagnosis and surgical management led to successful outcome in our patient. A non-invasive method including transthoracic echocardiography and computed tomography can be used successfully to diagnose penetrating cardiac injury.
References
Asensio JA, Berne JD, Demetriades D. One hundred and five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma 1998;44:1073–1082.
Nagy KK, Lohmann C, Kim Do, Barrett J. Role of echocardiography in the diagnosis of occult penetrating cardiac injury. J Trauma 1995;38:859–862.
Vosswinkel JA, Bilfinger TV. Cardiac nail gun injuries: lessons learned. J Trauma 1999;47:588–590.
De Cou JM, Abrams RS, Miller RS, Touloukian RJ, Gauderer MW. Life-threatening air rifle injuries to the heart in three boys. J Pediatr Surg 2000;35:785–787.
Rhen L. über penetirende Herzwunden and Herznaht. Arch Klin Chir 1897;55:315.
Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries. Ann Thorac Surg 1991;51:711–715.(Leo A. Bockeria and Hassa)
Abstract
Unusual penetrating injury of the heart in a 10-year-old child is described. The patient was admitted because of clinical symptoms of acute infection. The accurate diagnosis was put on echocardiography and computed tomography. After sternotomy, no evidence of previous heart injury was noted. A piece of metal from a terrorism-related bomb explosion was located within the free wall of the right ventricle. The urgent surgery led to full recovery of the child.
Key Words: Penetrating cardiac trauma
1. Introduction
Penetrating trauma of the heart for various reasons has been reported [1–4]. Recently, the incidence of heart injury, secondary to a terrorism bomb explosion, unfortunately, has increased. The aim of this presentation is to demonstrate the role of accurate preoperative imaging and emergent surgery in good outcome of this rare case.
2. Case report
A 10-year-old boy was admitted to our center with fever (40 °C), dyspnoea, anxiety, and hepatomegaly. Ten days previously during the opening ceremony of the new School Year in Beslan (September 1st) the school was invaded with this child, other children and their parents, by terrorists and managed to escape from the school building after bomb explosions. No further follow-up was performed after initial resuscitation at the regional hospital. On the 7th day the above claims have been mentioned. The X-ray showed a foreign body in the chest, superimposed on cardiac silhouette.
On physical examination of the chest, there was a 2 cm scar in the pectoral region to the left side of the sternum. He had no murmur on auscultation. The transthoracic echocardiography identified a piece of metal, located within the right ventricle (RV) (Fig. 1). Severe tricuspid insufficiency was detected with color flow Doppler. Computed tomography of the thorax confirmed diagnosis and suggested that the foreign body was situated in the free wall of the RV.
Due to the high temperature, clinical symptoms of acute infection and the patient's increasing anxiety, he was scheduled for emergent operation.
At median sternotomy, a hole in the pericardium 2 cm in diameter was found, but there was no evidence of previous heart injury. Intraoperative transesophageal echocardiography was made and location of the foreign body in the wall of the RV was confirmed. Cardiopulmonary bypass was established. Both vena cava were snared and the operation was performed on beating heart under moderate hypothermic cardiopulmonary bypass. The right atrium was opened. A piece of metal with a sharp margin (20x20x15 mm) was found within the free wall of the RV, immediately underneath the anterior leaflet of the tricuspid valve (Fig. 2). The anterior tricuspid leaflet was longitudinal ruptured. Large vegetation attached to the foreign body were seen. The metal was removed with extensive resection of the surrounding infected tissue. The hole, made in the free wall of the RV was repaired directly with a continuous suture. Five stitches repair of the anterior tricuspid leaflet was performed with a 5-0 polypropylene suture.
Postoperatively, the patient made a good recovery. Antibiotic administration was stopped on postoperative day 14. Postoperative two-dimensional echocardiogram revealed no regurgitation on the tricuspid valve. The patient was discharged in good condition.
3. Discussion
The first successful repair of a penetrating cardiac wound was reported by Rhen in 1897 [5]. This date has been suggested to be the starting point of the era of surgery on the heart.
Although patients with stab wounds of the heart usually survive when treatment is adequate, patients with missile wounds have far less successful results [6].
Our case could be interesting for the following:
First, a shrapnel penetrated the thorax and pericardium and rested within the right ventricle. However, during surgery we did not find evidence for hemorrhage.
Second, the child remained symptomatic after the injury until he presented 7 days later. The main symptoms of dyspnea and hepatomegaly were leaded to severe tricuspid regurgitation. Intra-operatively, the anterior tricuspid leaflet was longitudinal ruptured, but without damage to subvalvar structures. So, the valve was simply repaired by suturing the (cleft) with interrupted sutures of 5-0 polypropylene.
Finally, the child was transferred to the operating room in the first hour after admission to our center. At operation a foreign body with the surrounding tissues were removed and sent for culture. The patient received intravenous antibiotics (Maxipin + Rifampicin) immediately after the operation. This therapy was adapted to the germ found in the blood and tissue cultures (streptococcus). Antibiotic therapy was continued with Amoxicillin, Rifampicin and Metronidazol for two weeks. It was discounted after verification of the absence of clinical symptoms and normalization of the systemic parameters of inflammation (normal blood counts, negative blood culture and especially – test of Procalcitonin – 0.17 (norm up to 0.5). During the hospital period his temperature remained normal. An outpatient clinic was used for follow up 12 weeks after discharge. No recurrent or persistent evidence of infection has been revealed.
4. Conclusion
Early diagnosis and surgical management led to successful outcome in our patient. A non-invasive method including transthoracic echocardiography and computed tomography can be used successfully to diagnose penetrating cardiac injury.
References
Asensio JA, Berne JD, Demetriades D. One hundred and five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma 1998;44:1073–1082.
Nagy KK, Lohmann C, Kim Do, Barrett J. Role of echocardiography in the diagnosis of occult penetrating cardiac injury. J Trauma 1995;38:859–862.
Vosswinkel JA, Bilfinger TV. Cardiac nail gun injuries: lessons learned. J Trauma 1999;47:588–590.
De Cou JM, Abrams RS, Miller RS, Touloukian RJ, Gauderer MW. Life-threatening air rifle injuries to the heart in three boys. J Pediatr Surg 2000;35:785–787.
Rhen L. über penetirende Herzwunden and Herznaht. Arch Klin Chir 1897;55:315.
Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries. Ann Thorac Surg 1991;51:711–715.(Leo A. Bockeria and Hassa)