Yao-Kuang Huang

Blunt traumatic cardiac rupture: therapeutic options and outcomes.

INTRODUCTION Cardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same. METHODS This is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome. RESULTS The study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18+/-5.7 (range: 25-43), 6.267+/-1.684 (range: 2.628-7.841), and 72.4+/-25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n=4), right atrial auricle (n=1), right ventricle (n=4), left ventricular contusion (n=1), and diffuse endomyocardial dissection over the right and left ventricles (n=1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state. CONCLUSIONS We proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.

Surgical Risk and Outcome of Repair Versus Replacement for Late Tricuspid Regurgitation in Redo Operation

BACKGROUND Late tricuspid regurgitation after previous cardiac operation remains controversial in terms of when to repair and who will benefit. We reviewed our surgical experiences and stratified the risk factors for death and morbidity. METHODS From September 2005 to September 2010, 77 consecutive patients (36 men [47%]) underwent redo open heart operations with the tricuspid valve (TV) procedure. Their mean age was 56±13 years (range, 27 to 83 years). TV repair was performed in 44 (57%) and TV replacement in 33 (43%): 23 received bioprostheses; 10 received mechanical prostheses. RESULTS Fourteen (18%) patients died after the operation. Risk factors of hospital death by multivariate analysis were age (>65 years), preoperative renal insufficiency (creatinine>2 mg/dL), and preoperative severe liver cirrhosis (Child classification C). Compared with the group that underwent TV repair, those who underwent TV replacement tended to have had previous TV operations (46% vs 9%; p<0.001) and preoperative Child class C liver cirrhosis (21% vs 2%; p=0.018). Although in-hospital mortality was insignificant (24% vs 14%; p=0.232), postoperative morbidities of tracheotomy, gastrointestinal bleeding, and late death were higher in the replacement group. CONCLUSIONS Patients who had previous TV operations and preoperative severe liver cirrhosis were more likely to undergo TV replacement in tricuspid reoperations. Compared with patients in the repair group, patients in the replacement group had higher morbidities and low late survival. Earlier intervention, before decompensated heart failure occurs, is warranted to improve the outcome.

Traumatic pericardial effusion: Impact of diagnostic and surgical approaches

INTRODUCTION In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion. PATIENTS AND METHODS Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center. RESULTS Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome. CONCLUSIONS Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.

COR TRIATRIATUM SINISTRUM: SURGICAL EXPERIENCE IN TAIWAN

PurposeCor triatriatum sinister, more commonly referred to as cor triatriatum (CT), is characterized by a common pulmonary venous chamber (proximal chamber) separated from the left atrium (distal chamber) by a fibromuscular septum. This report of our experience updates the surgical results of this anomaly in the Asian population.MethodsBetween January 1992 and May 2005, nine patients with cor triatriatum underwent surgical correction at Chang Gung Memorial Hospital. We retrospectively analyzed their cardiac anatomy, clinical data, surgical procedures and follow-up data.ResultsThe mean age at surgery was 260 ± 215 days (range, 20–790 days), with the exception of one patient who underwent surgery at 31 years of age. Three patients had a partial anomalous pulmonary venous connection, one had a complete atrioventricular canal defect, and one had another major complex cardiac anomaly. Eight corrective operations and one palliative operation were performed. There was no surgical mortality. The mean follow-up time was 52.1 ± 43.6 months (range, 17–139 months).ConclusionOur findings show that surgical correction is efficient and safe for this rare cardiac anomaly.