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Background: Atrioventricular disruption (AVD) is a rare (1%-2%) but fatal complication after mitral valve procedures; the intraoperative mortality is more than 50% despite the current standard procedure of surgical closure of the defect. We compared the outcome of 9 patients with intraoperative AV disruption, 4 being surgically treated on-pump and 5 receiving epicardial tissue sealing off-pump., Methods: Between March 1998 and May 2002 a total of 9 patients presented with AV disruption intraoperative. The first 4 patients were treated with surgical repair on-pump by reconstruction of the defects with patch or buttressed suture. The second series of 5 patients were treated with a biodegradable collagen system with fibrinogen-based coating off-pump. Three to six layers were placed over the bleeding site with manual pressure for 30-60 minutes on the beating heart until bleeding was stopped. Cell saved blood was retransfused., Results: In the on-pump surgical repair group 3 patients (75%) died within the first day after repair either because of persistent bleeding or cardiac tamponade. One patient survived at 30 days and 1 year. In the off-pump tissue sealing group 30 days and 1 year survival was 100%. Postoperative echocardiography showed normal left ventricular (LV) function with no regional wall motion abnormalities., Conclusions: Our data show that epicardial tissue sealing off-pump results in successful termination of bleeding from AVD and considerably improves survival when compared with the standard procedure. Because of this tremendous improvement in patient survival we now consider this technique as standard therapy for AV disruption in our center.

A case of 80-year-old woman who died of hemorrhagic shock as a consequence of multiple heart and pericardial lacerations as well as myocardial contusion due to blunt trauma from assault is reported. At postmortem examination, fractures of the body of the sternum and bilateral ribs were detected. A laceration of the anterior left-sided pericardium, a 2.8-cm linear tear in the right venous sinus from the origin of the inferior to the origin of the superior vena cava, a 3-cm laceration between the venous sinus and the right auricle, and a 2-cm tear in the anterior wall of the left atrium, behind the aortic trunk, were visible. Multiple heart and pericardial lacerations were thought to be caused by compression of the heart between sternum and vertebrae, together with multiple rib fractures and extensive movements of the sternum toward the spine as a result of kicking.

Objectives: The effect of oxidative stress on coronary microvascular disease is unknown. We investigated whether chronic administration of ascorbic acid (ASC) or glutathione (GSH) prevents microvascular dysfunction and remodeling induced by upstream repeated coronary artery endothelial injury., Methods: Balloon endothelial injury was repeated at the left anterior descending coronary artery (LAD), just distal to an implanted flow meter, every 2 weeks for 6 weeks in pigs. Changes in LAD blood flow induced by acetylcholine (ACh) and 5-hydroxytryptamine were assessed before each endothelial injury and at 8 weeks after the first endothelial injury in pigs without treatment (endothelial injury group, n = 12) and in pigs treated with oral ASC (3 g/day) (ASC group, n = 12) and ASC (3 g/day) plus GSH (1 g/day) (ASC + GSH group, n = 12)., Results: In the endothelial injury group, reduced blood flow in response to ACh was augmented from a decrease of 18 +/- 17% to a decrease of 100% (that is, zero flow, 8 weeks, P < 0.01), accompanied by an increase of ascorbyl free radicals (AFRs) in coronary sinus blood. In contrast, in the ASC + GSH group, blood flow response to ACh was altered to a decrease of 45 +/- 17% (8 weeks, P < 0.01 compared with the endothelial injury group), coronary sinus blood AFRs did not change (8 weeks, 21.4 +/- 12.5 signal intensities, P < 0.01 compared with the endothelial injury group) and the rate of platelet aggregation induced by adenosine diphosphate was small (8 weeks, 56 +/- 17%, P < 0.01 compared with the endothelial injury group)., Conclusions: Chronic administration of antioxidants suppressed microvascular hypercontraction, suggesting that it may be a promising therapeutic strategy for treating coronary microvessel disorders, including microvascular angina., (Copyright 2004 Lippincott Williams & Wilkins)

The use of the subxiphoid pericardial window (SPW) in evaluating stable patients with cardiac proximity injuries is presented in a short case series. There were 11 patients with four positive and seven negative SPW. There was one false positive and no false negatives. Review of the literature on the use of the SPW as a diagnostic tool in evaluating cardiac proximity injuries shows the SPW to be a rapid and reliable method of detecting occult cardiac injuries, and is especially useful in areas where emergency echocardiography is not available.

A 65-year-old retired professional boxer presented with progressively worsening shortness of breath, peripheral oedema and mild abdominal swelling over a period of 6 months. His only past medical history was hypertension. Subsequent investigations revealed chylous ascites, pericardial constriction and bilateral chylothorax. He had uneventful pericardectomy, and post-operatively the chylothorax resolved only after administration of octreotide for 10 days. The histopathological features of fibrosis, haemosiderin deposition in the pericardium and abundant haemosiderin-laden macrophages are consistent with chronic resolving haemopericardium. These findings suggested that the cause of pericardial constriction was repeated chest trauma from boxing.

Nonpenetrating chest trauma can cause cardiac rupture. Ventricles are affected more frequently than atria. Survival is rare and depends upon prompt diagnosis and immediate surgical intervention. We report the case of a 42-year-old man involved in a car accident with consequent right atrial rupture and pericardial tearing.

Thermal denaturation can induce marked changes in the optical and mechanical properties of collagenous tissues. The optical properties are important in both therapeutic and diagnostic applications of lasers in medicine. Although mechanical stress can be caused by collagen shrinkage in laser-based therapies, how the mechanical loading state affects the optical properties is not well understood. We used a new computer-controlled biaxial testing system to subject bovine epicardium to various loading conditions both before and after multiple levels of thermal damage. An integrating sphere technique was used to measure transmittance and diffuse reflectance, from which absorption and scattering coefficients were calculated using a Monte Carlo method. Results showed that the scattering coefficient increased with increasing mechanical load but decreased as the degree of thermal damage increased. There was no significant change in the absorption coefficient due to thermal damage over the ranges studied.

Injuries by meat- or barbecue-skewers are rarely relevant as cause of death. Besides accidental injuries they are used as coincidental tools in capital crimes. Skewers are non-typical stabbing tools of pointed-squared structure, which need considerable force to penetrate the skin. The authors report on a 42-year-old man's fatal thorax stab injury, which he sustained during a barbecue and which stretched from the left mamilla into the back right shoulder tissue. Death was caused by exanguination following stabbing through the superior vena cava. At issue was the question what amount of force was necessary to inflict the wound. Based on the deformation of the stabbing tool, as a result of a material-technical expertise, compressive load application in longitudinal direction and a stabbing force of between 120 to 665 N were to be assumed. Furthermore, in addition to the features of a non-typical tool, the autopsy findings allowed to conclude a powerful stabbing.

The finding of a pericardial effusion in the pediatric population evokes an extensive list of differential diagnoses. With the added history of trauma the effusion should be considered secondary to hemorrhage. We present a patient with such a history who was admitted to the hospital with the finding of a large pericardial effusion and an associated pericardial mass. The evaluation and treatment of this rare pathology are discussed as well as a review of the literature.

Needle localized breast biopsy is commonly used to diagnose and remove non-palpable breast lesions. We present the first case of cardiac injury resulting from needle localized breast biopsy. A hooked-end monofilament wire penetrated the pericardium and myocardium overlying the left ventricle. The wire was pulled and the patient managed non-operatively with close monitoring that included plain chest radiographs, electrocardiography, and echocardiography. The literature regarding complications of the procedure was reviewed., (Copyright 2003 Wiley-Liss, Inc.)

Pericardial rupture after blunt chest trauma is rare and is associated with a high mortality rate. We describe a patient with traumatic pericardial rupture and cardiac herniation who was successfully treated surgically. Traumatic pericardial rupture is difficult to diagnose preoperatively but should be suspected whenever there is severe blunt chest trauma. If pericardial rupture is not recognized and treated promptly it could be fatal owing to cardiac herniation.

Rupture of the pericardium with luxation of the heart after blunt trauma is a fairly rare condition but carries a high mortality rate. In this report, we describe our experience with a case of right luxation of the heart in a young patient with multiple injuries due to an automobile accident. The patient, who was in hemodynamic failure, underwent successful emergency surgical treatment to replace the heart in its anatomic site. We discuss the diagnosis and management of this dangerous event.

This report describes a 21-year-old man who presented with pericardial hemorrhage due to a puncture wound of the pericardium by an inward-facing exostosis of the left fifth rib.

Purpose: To report a rare, fatal complication of superior vena cava Wallstent implantation., Case Report: A 59-year-old man presenting with superior vena cava syndrome caused by small-cell lung cancer underwent stent implantation of 2 kissing Wallstents >1.5 cm above the right atrium. Despite correct stent deployment, vessel perforation occurred in a section not encased by tumor, which led to fatal pericardial tamponade shortly after the procedure. Autopsy revealed perforation of a stent strut through the caval wall into the pericardial space. Anatomical and methodological reasons are discussed., Conclusions: The interventionist should be aware of this rare complication. Alternative stent designs avoiding the sharp ends of Wallstents and Palmaz stents should be considered.

The mechanical behavior of sutured ostrich pericardium was studied by uniaxial tensile testing. One hundred forty-four tissue specimens were assessed: 96 sutured samples (48 in which a centrally located suture was placed at an angle of 90 degrees with respect to the longitudinal axis, whereas in the remaining 48, a centrally located suture was placed at a 45 degrees angle to the longitudinal axis, in sets of 12 samples each, sewn with sutures made of Gore-Tex, nylon, Prolene, or silk), and 48 unsutured controls. Each group of 24 samples sewn at one angle or the other with the different suture materials was assayed together with a corresponding control group of 12 unsutured samples. The mean tensile strengths in the unsutured controls ranged between 30.16 MPa and 43.42 MPa, whereas those of the sutured sets ranged from 14.68 MPa to 21.91 MPa. The latter presented a statistically significant loss of resistance (p < 0.01) when compared with the unsutured tissue samples. The angle of the suture with respect to the longitudinal axis influenced the degree of shear stress produced by the suture, as well as the behavior of the different suture materials used. The set of samples sewn with Prolene appeared to be that most sensitive to changes in the angle of the suture, whereas tissue sewn at a 45 degrees angle with Gore-Tex presented lower shear stress values in comparison with samples in which the other three materials were used. A method of tissue selection based on morphological and mechanical criteria was used to ensure the homogeneity of the results in such a way that the coefficients of determination (R2) for the stress/strain curve fitting equation ranged between 0.888 and 0.995. This excellent fit made it possible, applying regression analysis, to predict the mechanical behavior of a specimen by determining that of a contiguous tissue sample. Thus, it should be possible, at least theoretically, to characterize the behavior of a specific region or zone of the biomaterial. In conclusion, ostrich pericardium exhibits strong resistance to rupture, even when sutured. The selection method used ensures the homogeneity of the samples and, thus, of the results. The angle of the suture with respect to the longitudinal axis, where the load is centered, determines the shear stress produced by the suture and the mechanical behavior of each suture material., (Copyright 2002 Wiley Periodicals, Inc.)

A thirty-years-old man with pectus excavatum was unconscious, in shock and with a history of blunt trauma of the chest and epigastrium admitted to hospital. After a short time he developed signs of pericardial and peritoneal effusion with tamponade and circulatory failure. Urgent laparotomy and sternotomy was performed. We found approximately a 5 cm long rupture of the right atrium, anterior wall of the intrapericardial part of the vena cava inferior with short extension to the infradiaphragmatic part of the vena cava inferior. We controlled bleeding by hand and by application of a Satinsky partial vascular clamp. Final plastic correction of the rupture was performed by implantation of a native autologous pericardial flap. After a complicated postoperative course the patient was discharged on the 37th postoperative day. Seven months after surgery the patient is in a good condition and has no signs of stenosis at the place of correction.

Background: Dislocation of the heart is a rare complication of thoracic blunt trauma. A high index of suspicion of pericardium rupture is necessary to formulate an early diagnosis to reduce morbidity and mortality., Patients: A 23-year-old man suffered a blunt thoracoabdominal trauma and was admitted 3 days later to a university hospital ICU for right heart luxation due to right pericardial tear. Mechanical ventilation delayed radiological findings., Methods and Results: Surgery by repositioning the heart and repairing the pericardial tear allowed restoration of hemodynamic equilibrium.

Cardiac rupture is certainly unrecognised in the context of closed chest trauma. There have been few reports in the literature despite the fact that autopsy series show that it is the second cause of death after serious thoracic injury. The authors report three cases of traumatic rupture of the heart. The clinical presentation, apart from cardiogenic shock, differs according to whether there is an associated rupture of the pericardium. When the pericardium is intact, the diagnosis is suggested by the signs of tamponade: With earlier treatment of trauma by medical teams, this lesion should be diagnosed as soon as possible. Echocardiography has many indications in closed chest trauma. Early surgical intervention is the only treatment of these lesions.

Survey radiography is used in diagnosis of different affections in buffaloes and cattle. The aim of the present study was to assess the role of radiography in diagnosis of reticular diaphragmatic hernias and traumatic pericarditis in buffaloes and cattle. The present study was carried out on 69 animals (51 buffaloes and 18 cattle). Reticular diaphragmatic hernias (40 buffaloes, 4 cattle) and traumatic pericarditis (11 buffaloes, 14 cattle) were evaluated. Lateral right-left survey radiography of the thorax was performed. In diaphragmatic hernia, radiography revealed presence of a rounded or vertical oval mass of soft tissue opacity superimposed over the heart. Radiopaque foreign bodies of variable shape and size were seen within the herniated part of the reticulum. The apex of the heart was difficult to visualize. With traumatic pericarditis, survey radiography of the thorax revealed poor differentiation of thoracic contents. The contour of the diaphragm was lost and the cardiac silhouette was obscured. In several animals radiopaque foreign bodies (sewing needles, nails, and pieces of wire) were detected at the level of the heart or in the area connecting the dome of the diaphragm with the heart.

Non-penetrating cardiac trauma resulting in mitral valve rupture is uncommon, requiring a high degree of suspicion for diagnosis. Sudden and severe mitral regurgitation, unless surgically corrected rapidly lead to congestive heart failure and death. We report a patient with traumatic rupture of the antero-lateral papillary muscle of the mitral valve and pericardial injury, after a lateral blunt chest trauma, who successfully underwent emergency mitral valve replacement.

Penetrating heart injury poses significant diagnostic and therapeutic challenges. Patients may initially appear in extremis or in stable condition. Surgeon-performed ultrasonography is effective in determining the presence or absence of tamponade. Definitive repair requires cardiorrhaphy, using a median sternotomy or thoracotomy incision, depending on the suspected injury site(s). Frequent postoperative complications can usually be managed without reoperation. Echocardiography, electrocardiography, and cardiac catheterization may be used postoperatively in reassessment. A patient with stab wounds to both ventricles of the heart is described.

Screw-in atrial pacing leads are widely used. Cardiac tamponade is a complication. An 81-year-old woman with advanced atrioventricular block underwent permanent pacemaker implantation and subsequently developed cardiac tamponade. At surgery, the lead-tip screw was found penetrated through the right atrium but not through the pericardium. The source of bleeding was confirmed to scratching the inner pericardial membrane by the screw tip. Although cardiac tamponade due to perforation and leakage is known, tamponade caused by the trauma of an atrial screw on the pericardium with resultant ooze is less well described.

Traumatic ruptures of the pericardium with cardiac herniation are infrequent, and their radiological pattern little familiar, so that they are often missed preoperatively. Few reports have emphasised the use of a CT scan as a tool for diagnosis and CT scan signs have not been well documented. We report on two cases of traumatic herniation of the heart for which a CT scan brought a major contribution for diagnosis. We describe the presence of an empty pericardial sac on CT slices which allowed us to diagnose the cardiac herniation. These observations demonstrate that CT scans can contribute to the diagnosis of pericardial rupture with cardiac herniation.

The experience of diagnosis and treatment of heart and pericardium wounds in 152 patients are presented. In obecure diagnosis the authors prefer X-ray examination and echocardiography. Total lethality was 23.6%. Its high level is due to injury of coronary arteries and intracardiac structures, other thoracic and abdominal organs. The left anterolaferal thoracotomy is the optimum approach in wounds of the heart and pericardium. The most frequent complication of postoperative period is pericarditis, its echographic symptoms were revealed in 91% examinys. Non-steroid and steroid antiinflammatory drugs are effective for prophylaxis and treatment of pericarditis.

A traumatic defect of the pericardium is a rarely diagnosed entity. We present a patient with a right-sided luxation of the heart which was incidentally diagnosed during a thoracic CT performed for other reasons. Despite of the threatening strangulation of the great vessels, the patient had a stable circulation until surgical repair of the pericardial defect.

Blunt rupture of the pericardium is a rare injury. Strangulated cardiac hernia following blunt trauma is one cause of reversible cardiac arrest. Traumatic pericardial tears usually have delayed diagnoses and carry high mortality rates (64%). Clinical signs mimic cardiac tamponade during the primary survey. We report here two cases of blunt trauma. Both patients arrived alive in the emergency room and presented signs of cardiac tamponade caused by pericardial rupture.

Results of the emergency diagnosis and surgical treatment of wounds of the heart and pericardium were summed up in 207 wounded during twenty years of work. It was found that injuries of the heart and pericardium were diagnosed in 42% of cases according to clinical symptoms, while emergency thoracotomy during the first minutes after admission to the surgical hospital was performed in 55-60% of wounded to the heart. About half wounded at the moment of admission to the hospital were at the state of relative stabilization of hemodynamic indices and had no clinical symptoms of wounds to the heart. In this group of patients injuries of the heart and pericardium were diagnosed on the basis of additional investigations, extrapleural pericardiotomy (fenestration of the pericardium) being most reliable. The results of treatment of wounded to the heart can be improved at the expense of acute surgical strategy which is determined by the stable state of the wounded, character of the myocardium injury and associated wounds.

A case of cardiac rupture following blunt trauma with no additional injuries is described. This can be a difficult diagnosis because of the presence of additional injuries and the lack of clinical symptoms. Here, there was a rupture of the pericardium, all chambers of the heart and the thoracic aorta.

Authors summarize their experiences connected with the treatment of open wounds of the heart and the pericardium during the past 35 years. Between 1962 and 1997 the authors operated on 31 cases of injuries affecting the heart. 10 wounds were situated in the isolated pericardium. They also deal with the history of treating injuries of the heart and pericardium. The value of diagnostical procedures was analysed and compared with Hungarian literature data that describes further cases. They emphasize the importance of immediate physical examination (including that of circulation, breathing, heart rate, consciousness, etc.) in cases of wounds close to the heart. Authors discuss the effects and the importance of the circumstances that directly affect the life expectancy of the patient during the treatment, such as time factor, the planning of cooperation within the operating team, practice in the field of thoracic surgery and management. They also put stress on correct thoracotomy, drainage and suction, so as to avoid postoperative pleural complications.

A 56-year old woman was admitted to the emergency ward after suffering a blunt thoraco-abdominal high-velocity trauma as she hit the wheel when her car drove into a tree. A laparotomy was performed because of haemodynamic instability and radiographic suspicion of a diaphragmatic rupture. Besides haemorrhage from liver and spleen injuries, an abdominal herniation of the heart through a ruptured pericardium and diaphragm was found. Haemostasis of liver, splenectomy and suturing of defects in pericardium and diaphragm resulted in a haemodynamically stable situation. A high index of suspicion of rupture of pericardium and diaphragm with luxation of the heart in the trauma patient is important to reduce morbidity and mortality due to delay of surgical intervention.