Penetrating cardiac injury is primarily caused by firearms, bladed weapons, or sharp objects. Firearm injuries often result in through-and-through cardiac wounds, with most victims succumbing at the scene. Retained foreign bodies within the heart are also common. Injuries from bladed weapons or sharp objects typically manifest as blind tract wounds. Iatrogenic cardiac penetrating injuries may occur during cardiac interventional procedures due to catheter manipulation. The most frequently affected sites are the right ventricle, left ventricle, right atrium, and left atrium, in descending order. Structures such as the interventricular septum and valves may also sustain damage. Cardiac catheterization-related injuries predominantly involve coronary artery or atrial perforations.
Clinical Presentation and Diagnosis
The pathophysiology and clinical manifestations of penetrating cardiac injury depend on the extent of pericardial and cardiac damage. When the injuring object has low kinetic energy, small pericardial and cardiac lacerations may become occluded by clots, leading to impaired drainage and subsequent cardiac tamponade. Clinical features include Beck’s triad (elevated venous pressure, distended neck veins, muffled heart sounds, weak cardiac pulsations, narrowed pulse pressure, and reduced arterial pressure). Prompt relief of tamponade and hemorrhage control are critical for survival.
High-energy injuries often cause large pericardial and cardiac lacerations, allowing rapid blood loss into the thoracic cavity. This typically manifests as hemorrhagic shock, with most fatalities occurring at the scene or during transport. A minority of patients may present with stable vital signs initially, accompanied by a history of chest trauma and small external wounds, which can delay diagnosis and treatment.
Key diagnostic criteria include:
- Chest wounds located within or near the cardiac projection zone on the body surface.
- Rapid onset of hemodynamic instability disproportionate to apparent blood loss.
- Presence of Beck’s triad or signs of hemorrhagic shock and massive hemothorax.
Given the rapid progression of penetrating cardiac injuries, reliance on conventional diagnostics (chest X-ray, ECG, echocardiography, or pericardiocentesis) may delay intervention. For patients with recent trauma, stable vital signs, and suspected cardiac involvement, urgent transfer to an operating room with thoracic surgical capabilities is essential. Bedside transthoracic or transesophageal echocardiography should be performed immediately. Pericardial effusion or tamponade findings warrant emergency thoracotomy to avoid missed resuscitation opportunities.
Management
Patients exhibiting cardiac tamponade or hemorrhagic shock require immediate transfer to an operating suite. Under general endotracheal anesthesia, pericardiotomy is performed to relieve tamponade, control bleeding, and initiate volume resuscitation. Autotransfusion of pericardial or thoracic blood may be utilized. Cardiac lacerations are repaired once hemodynamic stability is achieved.
Iatrogenic injuries from interventional procedures, often caused by guidewire perforations, typically involve small defects. Management includes procedure termination, heparin reversal with protamine, and pericardiocentesis. Serial echocardiographic monitoring guides further intervention. Persistent bleeding or hemodynamic instability necessitates surgical repair.
Institutions with advanced capabilities should consider cardiopulmonary bypass support for complex cardiac lacerations or concurrent management of underlying cardiac pathologies. Survivors require evaluation for retained intracardiac/pericardial foreign bodies and complications such as traumatic ventricular septal defects, valvular injuries, ventricular aneurysms, arrhythmias, pseudoaneurysms, or pericarditis. Long-term follow-up is critical to address residual cardiac abnormalities.