Sutureless Repair of a Full-Thickness Cardiac Stab Wound Adjacent to the Right Coronary Artery Using Evarrest® Patch

Abstract

Penetrating cardiac injuries provide a difficult and life-threatening problem to even the most experienced trauma surgeon. Often these patients present in extremis, making a rapid diagnosis and treatment essential. Traditionally, these injuries are treated by timely surgical repair, using a variety of suturing techniques. Challenges arise when the injury occurs adjacent to one or more cardiac vessels. In the past, deep mattress sutures, pledgeted repair, or in some cases, ligation with subsequent cardiac bypass of the affected vessel has been used.1 With the advent of new topical hemostatic agents, such as Evarrest (Ethicon, Inc., Somerville, NJ), a topical flexible fibrin sealant patch, the possibility exists to forgo a more conventional suture repair. A 38-year-old man presented as a trauma alert to Cooper Hospital, an ACS-verified Level 1 urban trauma center, after two self-inflicted stab wounds to the chest. On arrival, Advanced Trauma Life Support protocol was initiated by the trauma team. The patient was intubated in the trauma bay. He was found to be tachycardic in the 130 beats per minute range and had a systolic blood pressure in the 90 mmHg range. On secondary survey, he was noted to have a 1-cm midsternal stab wound, as well as a 2-cm parasternal stab wound over the left sixth intercostal space with active bleeding. Chest X-ray showed a white out of the left hemithorax and a focused assessment with sonography in trauma examination was performed which was positive in the pericardial view. He was, then taken emergently to the operating room where a left chest tube was placed with 1 L of blood return. He concomitantly underwent a decompressive subxiphoid pericardial, window which was positive for blood. This was immediately followed by a median sternotomy. His heart was evaluated, and he was noted to have a small 5-mm stab wound to the right ventricle abutting the right coronary artery (RCA) at the bifurcation of the right ventricular branch of the RCA (Fig. 1 A). Because a conventional suture repair of the stab wound could potentially cause ischemic injury to the RCA or the subsequent branch, the decision was made to place an Evarrest patch over the wound instead (Fig. 1 B). After allowing the Evarrest to adhere as per manufacture specifications, hemostasis was achieved. His left lung was examined, and a small stab wound was noted to the left lower lobe, and a small wedge resection was performed. After placement of two chest tubes and a mediastinal drain, the patient was closed. He was transferred to the surgical intensive care unit postoperatively for further monitoring. The remainder of his hospital course was uneventful; he was eventually downgraded to the floor, and ultimately discharged home from the hospital without need for any further interventions. The patient did not follow up in clinic as instructed, but routinely returned to the ED at our institution for issues unrelated to his cardiac injury and was evaluated by the trauma service each time. His postoperative EKG at 6 weeks showed no evidence of ischemic changes from his repair (Fig. 2). Topical hemostatic agents have gained increasing popularity over the years, particularly in trauma operations.2 They can be used as adjuncts to conventional repair techniques or as definitive repair options in areas in which tissue friability or potential vascular compromise is of great concern. Evarrest is a fibrin sealant patch with a biologic backing which provides additional structural durability. This agent provides an advantageous platform for repair, particularly in cases where active bleeding occurs in areas of tissue friability.3 Its structural Address correspondence and reprint requests to Christopher A. Butts, Ph.D., D.O., Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6300, New Brunswick, NJ 08901. E-mail: [email protected]. Author contributions: Christopher A. Butts and Joshua P. Hazelton designed this study. Christopher A. Butts, Ashleigh Hagaman, John Porter, and Joshua P. Hazelton participated in the manuscript preparation and critical revisions of the manuscript.