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Iatrogenic cardiac injury due to diagnostic sternal puncture occurred in 5 patients, 2 women and 3 men, aged 14 to 37 years. Four cases ended fataly but 1 patient survived after immediate thoracotomy and suture of the damaged heart. Perforation of the anterior wall of the right ventricle resulting in pericardial tamponade was present in all patients. All fatalities resulted in conviction, under criminal law, of the clinician who carried out the puncture (Paragraph 222 StGB--causing death through negligence).

Based on an analysis of literature and 45 personal observations the authors make a conclusion that reduction of lethality following wounds of the heart can be reached by introducing certain changes into traditional approaches to the problem. In order to approximate the moment of medical aid to the victims thoracotomy for the liquidation of heart tamponade, arrest of bleeding should be performed at the place of accident or in the admission department of the hospital, even to the detriment of traditional requirements of asepsis. For the prevention and treatment of early and late complications the patients must be directed to specialized centers (thoracal departments of the hospitals). The introduction of counterpulsation of the aorta, pacemakers, auxiliary blood circulation should be considered as requirements of time.

Fatal complications of sternal puncture are, as a rule, the result of penetration of the needle through the sternum followed by lesion of the pericardium and myocardium and finally pericardial tamponade and death. Thirty-four such cases are studied with a view to the technique and especially the site on the sternum where the puncture was made. It was supposed that the punctures in the sternum in the fatal cases were performed below the level of the second intercostal space and that that was the primary cause of the fatal outcome as the heart and pericardium here are very close to the sternum. Punctures at the level of the second intercostal space and higher should be reasonably safe. To the astonishment of the author, it was found that many of the fatal punctures were made in the sternum at the level of the second intercostal space or higher. The many reports in the literature were examined again and it was concluded that the complications might be due to inexperience and lack of training of the person who performed the puncture. It is concluded that puncture of the iliac crest with marrow aspiration and biopsy is preferable for better diagnostic value and a safer procedure.

The experience with the treatment of 93 patients with knife injury to the heart and pericardium is summarized. The only proper therapeutical tactics in injury to the heart and pericardium is the emergency performance of operative intervention. The therapeutical value of pericardial punction is doubtful. Good results of treatment were achieved after the use of blood reinfusion. Fourteen (15.1%) patients died.

An unusual penetrating chest injury was caused by a ball-point pen. Because of apparent penetration of the heart, preparations were made for an emergency open-heart procedure before emergency thoracotomy was undertaken, with the pen still in situ. The pen had bruised the epicardium but had not penetrated the pericardial sac. After removal of the pen, the wound was closed and a chest tube left in place. Recovery, apart from minor degrees of basal atelectasis, pleural effusion and wound infection, was uneventful. The outcome was consistent with that associated with current aggressive management of penetrating chest injuries. Management is based on three approaches. The primary one is intercostal thoracostomy tube drainage and fluid and blood replacement. In cases of massive hemorrhage or air leak, thoracotomy is necessary. The third approach is to prevent post-traumatic pulmonary insufficiency by using fine, high-efficiency filters during blood transfusion, avoiding excessive administration of intravenous fluids, performing tracheostomy after prolonged endotracheal intubation, and using a volume respirator with positive end-expiratory pressure. The average mortality for penetrating wounds of the heart is 25%.

Wounds of the heart and pericardium were observed in 19 patients. Four patients died. The main causes of death were acute blood loss, shock, tamponade of the heart. Urgent operations are indicated to all the patients with wounds in the cardiac area. The outcome of the surgery is dependent on the rapid and efficient operation and adequate blood supply.

The records of 24 patients who had a missile retained in the heart and who were treated at Grady Memorial Hospital from 1968 to 1987 were reviewed. In 22, the missile lodged in the heart after its direct injury and in the remaining 2, after the bullet injured a systemic vein. Immediately after the cardiac injury, 7 of the 22 patients were seen with cardiac tamponade (3 also had hemothorax), 11 were seen with hemothorax, 5 were asymptomatic, and 1 was in shock. Seven patients underwent emergency thoracotomy; the bullet was removed in 3, but in the remaining 4 patients, it was not located. In the other 17 patients and in the 4 in whom the bullet could not be found during emergency thoracotomy, the diagnosis was suspected from the chest roentgenograms and confirmed by cardiac fluoroscopy or angiocardiography. Eight patients with retained bullets underwent elective operation; the bullet was removed from 7 and in 1 it was left embedded in the right ventricular septum. All 10 patients who underwent excision of the missile recovered without complication except 1 in whom pericarditis developed, and all were followed for up to 17 years. All 14 patients with a retained missile in the heart had no cardiac symptoms referable to the bullet and were followed for up to 15 years. This experience suggests that the management of patients with a bullet of .38 caliber or smaller that is retained in the heart should be individualized according to the patient's clinical course and the site of the bullet and that in select patients, bullets left in the heart are tolerated well.

The authors experience with surgical treatment of heart and pericardium injuries is summarized. A total of 38 patients were operated upon. The surgical aid consisted in simultaneous performance of the complex of reanimation measures, urgent thoracotomy and suturing of the heart wound. Thirty six patients have recovered, two died. One patient died due to mediastinitis, the other -- due to progressive cardiovascular insufficiency.

Eighty seven patients with heart injury were treated. Eighteen sufferers died. The success of treatment largely depends on organization of giving surgical aid.

An analysis of 136 clinical observations has shown that clinical symptoms and additional methods of examination (X-ray analysis of the chest, ECG, puncture of the pleura and pericardium) are sufficient for timely diagnosis of wounds of the heart and pericardium. The necessity of urgent operation prevents using complex diagnostic methods. Outcomes of the treatment are dependent on the time of admission of the patient to the hospital and timely operative interventions.

Trauma is the third leading cause of death in the United States and the leading cause for persons under 40 years of age; chest trauma accounts for more than 25% of these deaths. Rates of trauma to the chest--both blunt and penetrating--are rising because of the continuing development of high-speed transportation and because of increasing inner-city violence combined with ready availability of handguns. But treatment has improved; even injury to the heart is no longer considered invariably lethal. This review describes the spectrum of injuries to the pericardium, heart, aorta, and thoracic arteries and veins, exclusive of iatrogenic trauma and high-velocity gun shot injuries caused by military weapons. The role of imaging is described.

A case is reported of a 33-year-old multiple injured patient with closed chest trauma and an unknown rupture of left pericardium and hemidiaphragm. A peroperative cardiac arrest, one year later, was related to dislocation of the heart. Thoracotomy for internal cardiac massage was responsible for a successful outcome.