Korean Journal of Thoracic and Cardiovascular Surgery 2016; 49(6): 435-442  https://doi.org/10.5090/kjtcs.2016.49.6.435
Blunt Traumatic Cardiac Rupture: Single-Institution Experiences over 14 Years
Jeong Hee Yun1, Joung Hun Byun2, Sung Hwan Kim2, Sung Ho Moon2, Hyun Oh Park2, Sang Won Hwang3, and Yong Hwan Kim4
1Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 2Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, 3Department of Thoracic and Cardiovascular Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 4Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine
Corresponding author: Joung Hun Byun, Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, 11 Samjeongja-ro, Seongsan-gu, Changwon 51472, Korea, (Tel) 82-55-214-1000 (Fax) 82-55-750-8800 (E-mail) jhunikr@naver.com
Received: March 24, 2016; Revised: August 25, 2016; Accepted: August 26, 2016.; Published online: December 5, 2016.
© The Korean Journal of Thoracic and Cardiovascular Surgery. All rights reserved.

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Abstract

Background

Blunt traumatic cardiac rupture is rare. However, such cardiac ruptures carry a high mortality rate. This study reviews our experience treating blunt traumatic cardiac rupture.

Methods

This retrospective study included 21 patients who experienced blunt traumatic cardiac rupture from 1999 to 2015. Every patient underwent surgery. Several variables were compared between survivors and fatalities.

Results

Sixteen of the 21 patients survived, and 5 (24%) died. No instances of intraoperative mortality occurred. The most common cause of injury was a traffic accident (81%). The right atrium was the most common location of injury (43%). Ten of the 21 patients were suspected to have cardiac tamponade. Significant differences were found in preoperative creatine kinase–myocardial band (CK-MB) levels (p=0.042) and platelet counts (p= 0.004) between the survivors and fatalities. The patients who died had higher preoperative Glasgow Coma Scale scores (p=0.007), worse Trauma and Injury Severity Scores (p=0.007), and higher Injury Severity Scores (p=0.004) than those who survived.

Conclusion

We found that elevated CK-MB levels, a low platelet count, and multi-organ traumatic injury were prognostic factors predicting poor outcomes of blunt cardiac rupture. If a patient with blunt traumatic cardiac rupture has these factors, clinicians should be especially attentive and respond promptly in order to save the patient’s life.

Keywords: Cardiac tamponade, Trauma, Rupture
Introduction

Blunt traumatic cardiac rupture is rare but highly fatal [13]. The incidence of blunt cardiac rupture among hospital admissions for trauma is only approximately 0.16%–2% [46]. However, the actual incidence may be higher because many victims may die before arrival at the hospital. With advances in traumatology, several studies have investigated the prognostic factors associated with traumatic cardiac rupture [1,7]. In this study, we attempted to find factors affecting the prognosis of patients with blunt traumatic cardiac rupture.

Methods

1) Patients

This retrospective study was reviewed and approved by the institutional ethics committee of our institution (Ethical Committee of Sungkyunkwan University of Samsung Changwon Hospital, approval number 2015-SCMC-037-00). Between 1999 and 2015, a total of 107,657 patients were admitted to our hospital due to trauma. We selected 47 patients who were diagnosed with traumatic cardiac rupture. We excluded patients with penetrating or iatrogenic cardiac rupture. Ultimately, we analyzed 21 patients who were diagnosed with blunt traumatic cardiac rupture and required emergency surgery. In our analysis of these 21 patients, we identified several prognostic factors.

2) Surgery

All operations were performed via median sternotomy. In each case, cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation was prepared as a precaution. If the patient was hemodynamically unstable, 2 cardiovascular surgeons operated together to perform the median sternotomy and femoral cannulation simultaneously. After the sternotomy, surgeons opened the pericardium for prompt decompression of the heart, rapidly removed the hematoma, and attempted to find the injury site. The injury sites were primarily repaired using double-arm monofilament stitches with pledgeted, interrupted sutures. After the injury sites were primarily repaired, we weaned the patients from CPB as soon as possible.

3) Statistical analysis

All data are expressed as means±standard deviations. Continuous variables were compared using the Mann-Whitney U-test. Categorical variables were compared using the chi-square test or the Fisher exact test. All p-values <0.05 were considered to indicate statistical significance. Data were analyzed using IBM SPSS ver. 21.0 (IBM Co., Armonk, NY, USA).

Results

The patients’ clinical characteristics are presented in Table 1. Most blunt traumatic cardiac injuries resulted from traffic accidents (81%), and most patients had combined trauma. The combined trauma included liver laceration, spleen injury, pelvic bone fracture, spinal fracture, and fractures of the extremities (Table 2). The mean Injury Severity Score (ISS) was 28±17.4 (range, 16 to 97).

Among the 21 patients, 10 were suspected to have cardiac tamponade, 3 of whom died after surgery. The mean central venous pressure (CVP) and systolic blood pressure of the 3 patients who died were 28 cm H2O and 67 mm Hg, respectively. In contrast, the mean CVP and systolic blood pressure of the 7 surviving patients were 26 cm H2O and 81 mm Hg, respectively.

Two patients received cardiopulmonary resuscitation (CPR) prior to surgery. One of them died during postoperative care due to pneumonia and the other survived.

CPB was used in 4 patients. Three of them had left ventricle injuries, and the other had a right atrium (RA)/inferior vena cava (IVC) junction injury. Among these 4 patients, 2 patients had major combined injuries (Table 2). Therefore, they underwent a co-operation (open reduction and vessel repair) to prevent additional bleeding due to systemic heparinization.

The preoperative lab findings, systolic blood pressure, and elapsed time from arrival to surgery are summarized in Table 3. Creatine kinase–myocardial band (CK-MB) levels (13.4±9.2 ng/mL) were elevated in most patients. In contrast, the preoperative creatinine levels (1.1±0.3 mg/dL) were nearly normal in all patients. The time from hospital arrival to surgery ranged from 10 to 260 minutes. In addition, the mean blood transfusion amount in survivors was 6.3 units, as compared to 9 units in fatalities (p=0.900).

A comparison between the survivors and fatalities is presented in Table 4. There were 16 survivors and 5 fatalities. No instances of intraoperative mortality occurred, but the in-hospital mortality rate was 24% (5 of 21). The causes of death included pneumonia (1), inadequate myocardial protection-related low cardiac output (1), and massive bleeding-related disseminated intravascular coagulation (3). All fatalities showed liver and renal failure, and 2 of them showed brain death. The clinical characteristics of each patient are presented in Table 2.

Significant differences were found in preoperative CK-MB levels (p=0.042) and platelet counts (p=0.004) between the survivors and fatalities. In addition, the preoperative Glasgow Coma Scale score (p=0.007), Trauma and Injury Severity Score (p=0.007), and ISS were significantly worse in the fatalities than in the survivors (p=0.004). No significant differences were found between the two groups in preoperative creatinine levels (p=0.495) or elapsed time to surgery (p=0.445). Similarly, no significant differences were found in injury location (p=0.437), CPR history (p= 0.372), use of CPB (p=0.182), amount of blood transfusion (p=0.900), or shock index (p=0.186) between the two groups.

Discussion

Most patients who experience blunt traumatic cardiac rupture die before arrival to the hospital. According to one Japanese study, 91% of patients with blunt traumatic cardiac rupture died within 30 minutes of the accident [7]. We analyzed 21 patients who experienced blunt traumatic cardiac rupture and compared our results with those of previous studies.

Most of our results are consistent with those of previous papers. Traffic accidents were the most common cause of blunt traumatic cardiac rupture (80%), and the most common site of injury was the right atrium (43%) [2,5,79]. However, some of our results were different from those of previous studies.

When a patient arrived at the hospital, we first focused on the vital signs, peripheral circulation, presence of an open wound, neck vein distension, and facial plethora. If cardiac rupture was suspected, we performed chest computed tomography, focused assessment with sonography for trauma, or transthoracic echocardiography as soon as possible. If patients had unstable vital signs, we performed intubation and transfusion, using intravenous inotropics as needed. If patients had hemopneumothorax, we inserted a chest tube at the emergency department and then rapidly transferred the patients to the operating room.

Ten of the 21 patients were suspected to have cardiac tamponade because they had hypotension, high CVP, and echocardiographic signs of tamponade (the presence of pericardial effusion, diastolic collapse of the right ventricle, IVC dilatation, etc.). When we suspected cardiac tamponade, we rapidly moved the patient to the operating room rather than trying to insert a pericardial catheter in the emergency room, because it takes almost the same time to perform a pericardial catheter insertion as to prepare the operating room in our hospital. The average elapsed door-to-surgery time in patients with cardiac tamponade was 29 minutes. In contrast, when cardiac tamponade was not suspected, further evaluations were performed prior to surgery.

If a patient’s vital signs are unstable, we consider an emergency department thoracotomy to have several advantages, including the prompt decompression of pericardial pressure and the rapid restoration of hemodynamics. However, our emergency room had no facilities available for emergency department thoracotomies.

All cases were performed via median sternotomy. CPB was applied in 4 patients with left ventricular rupture, and in 1 patient with an RA/IVC junction injury.

Sixteen (75%) of the 21 patients survived. The overall survival rate was similar to that of a prior study, which found that 70%–80% of patients who were transferred to trauma centers survived after blunt cardiac injury [8].

Several discrepancies are present between our results and those of Nan et al. [4]. They found significant differences between survivors and fatalities in preoperative creatinine levels, but no differences in preoperative CK-MB or platelet count [4]. In contrast, we found no significant difference in preoperative creatinine levels between survivors and fatalities. In addition, our results revealed significant differences in preoperative CK-MB levels and platelet counts between the two groups.

Several possible reasons exist for these discrepancies. Patients with impaired renal function preoperatively would be expected to have poorer postoperative outcomes than those with normal renal function. In our study, however, all patients had normal preoperative creatinine levels. This may explain why we did not identify a significant difference between survivors and fatalities.

Elevated preoperative CK-MB may be associated with a poor prognosis. This enzyme is not specific for cardiac injury, but can reflect severe muscle injury and potentially predict rhabdomyolysis. According to a 1998 study by Swaanenburg et al. [10], among 38 patients with thoracic injuries, 18–30 had increased CK-MB levels, increased CK-MB activity, an elevated ratio of CK-MB activity to total CK, or an elevated ratio of CK-MB mass to total CK upon admission. Although elevated CK-MB levels are not specific for cardiac injury, they can be indicative of severe combined injuries and be associated with a poor prognosis.

In addition, a low preoperative platelet count may also be associated with a poor prognosis. Nijboer et al. [11] recently reported that the early-stage platelet count was independently related to mortality in blunt trauma patients. A low platelet count reflects increased platelet consumption as well as massive blood loss and hemodilution. Increased platelet consumption can lead to a systemic inflammatory response or disseminated intravascular coagulation [11]. Early platelet consumption can be explained based on the fact that platelet aggregation and blood clot formation begins within 15–20 seconds of a major vessel rupture [12].

We did not find any significant difference in elapsed time from hospital arrival to surgery between fatalities and survivors. Disease severity may have acted as a suppressor variable. For instance, when a patient was suspected to have cardiac tamponade, surgery was promptly performed within 30 minutes. In contrast, surgery was delayed more in hemodynamically stable patients.

1) Study limitations

This was a case-control study, and case-control studies are prone to bias and confounding. The small, heterogeneous study population is a major limitation of this study. Although we were able to identify some characteristics of survivors, we were not able to clearly confirm causality. Given this limitation, we attempted to identify factors associated with a poor prognosis. Larger studies in the future are needed to substantiate our findings.

2) Conclusion

Few prior studies have investigated blunt traumatic cardiac rupture due to the rarity of such cases. This study analyzed factors associated with a poor prognosis of blunt traumatic cardiac rupture. We found that elevated CK-MB levels, a low platelet count, and multi-organ traumatic injury were associated with a poor prognosis (Fig. 1). If a patient with blunt traumatic cardiac rupture exhibits these factors, clinicians should be especially attentive and respond promptly to save the patient’s life.

Acknowledgments

This study was supported by a Grant of the Samsung Vein Clinic Network (Daejeon, Anyang, Cheongju, Cheonan; Fund No. KTCS04-060).

Figures
Fig. 1. Elevated CL-MB, a low platelet count, and multi-organ traumatic injuries were associated with a poor prognosis after blunt traumatic cardiac injury. CK-MB, creatine kinase–myocardial band isoenzyme.
Tables

Patient characteristics

CharacteristicValue
Age (yr)48 (17–95)
Gender
 Male13 (62)
 Female8 (38)
Cause of trauma
 Fall2 (9.7)
 Motor vehicle accident
  Inside car11 (52.0)
  Pedestrian4 (19.0)
 Motorcycle2 (9.7)
 Industrial accident2 (9.7)
Injury location
 Left atrium2 (9.7)
 RA9 (43.0)
 RA/superior vena cava2 (9.7)
 RA/IVC1 (4.8)
 RV/IVC1 (4.8)
 Left ventricle3 (14.0)
 RV3 (14.0)
Diagnostic method
 Chest CT10 (48.0)
 Echocardiography7 (33.0)
 CT/echocardiography4 (19.0)
Cardiopulmonary bypass4 (19.0)
Cardiopulmonary resuscitation2 (9.7)
Ventilator care time (hr)111±318.8
Hospital stay duration (day)36±35.9
Intensive care unit stay duration (day)17±29.3

Values are presented as median (range), number (%), or mean±standard deviation.

RA, right atrium; IVC, inferior vena cava; RV, right ventricle; CT, computed tomography.

Age, sex, injury mechanism, injury sites, combined injury, injury score, injury severity, hospital course, and outcome of patients

No.Age (yr)SexMechanismInjury locationCombined injuryInjury Severity ScoreTamponadeShock indexa)Cardiopulmonary resuscitationCardiopulmonary bypassHospital day (day)Intensive care unit stay day (day)Cause of deathOutcome
139FMVARA-SVCPneumothorax, Rt. patella fracture21No0.65NoNo158-Alive
225MPedestrianRADiffuse axonal injury, Lt. renal contusion, liver contusion, Lt. hip fracture24No2.5NoNo9242-Alive
335FMVARA-SVCRt. radius fracture, intrahepatic hematoma24No0.86NoNo184-Alive
419MMVARANo16Yes2.26NoNo134-Alive
559MIndustrialRVNo16Yes0.9NoNo374-Alive
667MMotorcycleRAHemopneumothorax (both), Rt. patella fracture, Rt. acetabular fracture21No0.9NoNo9955-Alive
717MMotorcycleRALiver laceration, Rt. renal injury, Rt. pubic bone fracture, Lt. facial bone fracture, cerebral contusion,26No2.7YesNo287-Alive
830FMVARAHypoxic brain damage, liver contusion, Rt. ankle fracture21Yes1.14NoNo218-Alive
950MIndustrialRV-IVCRt. wrist fracture20Yes1.13NoNo265-Alive
1039FMVARALiver laceration, cerebral concussion26No1.51NoNo159-Alive
1152FPedestrianRASpleen laceration24Yes1.56NoNo283-Alive
1247MMVARVNo16Yes1.61NoNo102-Alive
1375FMVARA-IVCLt. humerus mid shaft fracture, facial laceration21No1.16NoYes828-Alive
1448MMVALVCerebral hemorrhage, panperitonitis, liver contusion, Rt. patellar fracture34No0.94NoNo7027-Alive
1573MMVALAPelvic bone fracture20No0.78NoNo164-Alive
1648MFall downLADistal jejunum mesenteric tearing34Yes1.33NoYes235-Alive
1727MPedestrianRAL-spine dislocation, paraplegia, hemopneumothorax, hemoperitoneum, liver contusion, GI bleeding42No1.44NoNo3130GI bleeding due to gastric ulcer, ARFDead
1836MMVARAHypoxic brain damage, Rt. pneumothorax97Yes1.73YesNo128128Pneumonia, brain deathDead
1948MMVALVRt. femur fracture20Yes2.46NoNo21Low cardiac output, brain deathDead
2031FFall downLVPelvic bone fracture, spleen laceration, both internal iliac artery rupture41No1.65NoYes22Hypovolemic shock, DIC, ARFDead
2195FPedestrianRVMultiple rib fracture, Lt. fibular fracture, Lt. pubic bone fracture24Yes0.97NoYes11DIC, hypovolemic shockDead

F, female; MVA, motor vehicle accident; RA, right atrium; SVC, superior vena cava; Rt., right; M, male; Lt., left; RV, right ventricle; IVC, inferior vena cava; LV, left ventricle; LA, left atrium; GI, gastrointestinal; ARF, acute renal failure; DIC, disseminated intravascular coagulation.

a)Heart rate/systolic blood pressure.

Mean preoperative measures

VariableValue
Creatine kinase-myocardial band isoenzyme (ng/mL)13.4±9.2
Troponin I (ng/dL)1.69±2.2
Hematocrit (g/dL)37.1±5.1
Platelet count (103/mL)189.2±7.2
Creatinine (mg/dL)1.1±0.3
Systolic blood pressure (mm Hg)80.9±21.9
Central venous pressure (cm H2O)19.2±8.8
Elapsed time from arrival to surgery (min)74.4±71.4

Values are presented as mean±standard deviation.

Comparison between survivors and fatalities

VariableSurvivors (n=16)Fatalities (n=5)p-value
Age (yr)50.3±15.350.2±310.842
Lactate (mmol/L)5.3±3.27.8±0.220.212
Creatine kinase–myocardial band isoenzyme (ng/mL)22.7±28.778.5±110.40.042
Troponin I (ng/dL)2.2±4.12.8±2.10.133
Creatinine (mg/dL)1.1±0.31.1±0.20.495
Hematocrit (g/dL)38.3±4.234.8±6.00.109
Platelet count (103/mL)196.8±53144.8±460.004
Central venous pressure (cm H2O)18.3±5.917.3±12.50.905
Elapsed time to surgery (min)66.1±62.4112.3±104.40.445
SBP (mm Hg)87±22.175±19.10.354
Ventilator care (hr)65.4±141.311.9±12.90.842
Hospital days (day)38.6±30.99.0±14.70.313
Intensive care unit stay duration (day)11.4±12.98.5±14.30.445
Injury Severity Score23.2±6.533.5±9.30.004
Glasgow Coma Scale13.7±2.56.8±4.60.007
Trauma and Injury Severity Score99.2±1.887.1±13.20.007
Blood transfusion (packs)6.43±2.989±8.970.900
Shock index (heart rate/SBP)1.3±0.561.65±0.540.186
Diagnostic method
 Chest CT8 (50.0)2 (40.0)0.696
 Echocardiography4 (25.0)3 (60.0)0.147
 CT and echocardiography4 (25.0)00.214
Injury location0.437
 Left atrium2 (12.5)0
 RA7 (43.8)2 (40.0)
 RA-superior vena cava2 (12.5)0
 RA-IVC1 (6.3)0
 RV-IVC1 (6.3)0
 Left ventricle1 (6.3)2 (40.0)
 RV2 (12.5)1 (20.0)
Cardiopulmonary bypass2 (12.5)2 (40.0)0.182
Cardiopulmonary resuscitation1 (6.3)1 (20.0)0.372

Values are presented as mean±standard deviation or number (%), unless otherwise stated.

SBP, systolic blood pressure; CT, computed tomography; RA, right atrium; IVC, inferior vena cava; RV, right ventricle.

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