Video-assisted thoracoscopic pericardial window for penetrating cardiac trauma.

OBJECTIVE: To report our experience with thoracoscopic pericardial window (TPW) for occult penetrating cardiac injury.

PATIENTS AND METHODS: During the study period (1 January - 31 December 2000), a small group of haemodynamically stable patients with anterior left-sided praecordial wounds were selected for TPW. All patients underwent general anaesthesia with double-lumen intubation and collapse of the left lung. A rigid laparoscope was inserted through a 2 cm incision in the 5th intercostal space in the anterior axillary line. Another 3 cm incision was made in the fourth intercostal space over the cardiac silhouette. Conventional instruments were used to grasp and open the pericardium. Any myocardial injury identified was an indication to proceed to sternotomy. In the absence of a myocardial injury and bleeding, the procedure was terminated and considered therapeutic.

RESULTS: Seventy-one patients with suspected penetrating cardiac injuries were seen. TPW was successfully completed in 13 patients. All were men, with a mean age of 29.8 (range 19 - 38) years. Ten and 3 patients sustained stab and gunshot wounds, respectively. The mean revised trauma score was 7.84. Ultrasound was performed in 12 patients; the results were equivocal for 2 patients, and positive for an effusion in 4 patients. Haemopericardium was found in 3 patients, 2 of whom proceeded to sternotomy. No cardiac injury was found in 1, a left ventricular contusion was identified in the second, and the third patient had no further procedure after good video-thoracoscopic visualisation of the anterior myocardium revealed no injury. In another patient, pericardial bruising was evident without any haemopericardium. The mean operative time was 13.4 (range 10 - 15) minutes, with a mean hospital stay of 5.4 (range 3 - 8) days. There were no complications. The use of a double-lumen endotracheal tube increased the cost of TPW by 23% when compared with subxiphoid pericardial window (SPW).

CONCLUSION: TPW is a feasible, although in our setting not cost-effective, diagnostic option for occult penetrating cardiac injuries.