Discussion

Mortality in penetrating cardiac injuries varies depending on the area of the injury, duration of transport and intervention, the presence of additional organ injury, the amount of blood loss that occurs, and the presence of tamponade. ^{Reference Carr, Buterakos, Bowling, Janson, Kralovich and Copeland3} At their studies on the penetrating cardiac injuries, Buckman, et al reported that 78% of all deaths occurred in the first hour after cardiac injury. ^{Reference Buckman, Badellino and Mauro4} In another similar study, Hardikar, et al stated that prehospital mortality rate was 70%-80%. ^{Reference Hardikar, Thakur, Karmarkar, Ambike, Kanetkar and Golhar5} Survival rate among the patients arriving at the hospital on time, receiving immediate diagnose, and getting quick surgical intervention if needed is shown to be 74%. ^{Reference Tyburski, Astra and Wilson6}

The major finding in heart injuries is usually cardiac tamponade. Although there was no cardiac tamponade in the present case, the patient was immediately taken into surgery room since his radiological evaluations and ECHO indicated heart injury.

One of the most important diagnostic criteria for heart injuries is the site and the direction of entry of the damaging factor into the body. ^{Reference Jebara and Scede7} In the present case, although the patient had an injury in the cervical region where cardiac injury would not have been considered in the first place, the results of brain CT, contrast thorax CT, and ECHO indicated heart injury, thereby facilitating instantaneous decision for the surgery. Present observation showed the importance of considering cardiac injury in differential diagnosis, regardless of hemodynamic stability.

The first assessment of the patient in the emergency room by a cardiovascular surgeon, implementation of radiological and ECHO tests on time, and rapid assessment of their results, in addition to findings showing heart injury and rapidly taking the patient in the emergency operation room, were life-saving for the patient. The time elapsed between the evaluation of the patient in the emergency room and the start of the operation was 27 minutes and the time between ECHO and the operating room was 20 minutes.

Several studies report that while mortality rate varies between 54%-94% in the patients developing cardiac arrest and receiving emergent intervention due to the arrest after penetrating heart injuries, it is shown to be reduced to 13.5%-40.0% in the patients receiving emergent intervention without cardiac arrest after penetrating heart injuries. ^{Reference Attar, Suter, Hankins, Sequeira and McLaughlin8–Reference Peter, Hugh and Christoph10} In the present case, although the initial ECHO of the patient revealed pericardial effusion not causing to cardiac tamponade, a tamponade clinic began developing in the period passed for taking the patient on the operation table. The onset of tamponade clinic pointed out presence of a potential active bleeding and prompted an urgent need for cardiopulmonary bypass. Even though left anterolateral thoracotomy is a preferable approach in the heart injuries, since it requires fewer surgical tools and offers a rapid access, median sternotomy method is often favored in the studies reported in the literature because it not only provides better entree to entire chambers of the heart, aorta, pulmonary arteries, and veins, but it also ensures better exploration and allows convenient switch to cardiopulmonary by-pass if necessary. ^{Reference Topaloğlu, Aras and Çağlı11–Reference Mitchell, Muakkassa, Poole, Rhodes and Griswold16} Accordingly, median sternotomy was preferred for the present case.

Numerous studies in the literature report higher mortality rate among the patients developing cardiac arrest or becoming hemodynamically unstable after penetrating heart injury. ^{Reference Attar, Suter, Hankins, Sequeira and McLaughlin8–Reference Peter, Hugh and Christoph10} The cases where cardiopulmonary bypass is needed for repair include major vascular and/or atrial/ventricular injury, excessive bleeding, or difficult access to the injury site. ^{Reference Asension, Berne and Demetriades9,Reference Mittal, McAleese, Young and Cohen17} In the present case, the sternotomy and pericardial opening procedures, along with simultaneous peripheral cannulation, were initiated prior to development of cardiac arrest and impairment of perfusion. In addition, cardiopulmonary bypass was also introduced when active bleeding was spotted in opened pericardium. This approach precluded the formation of hemodynamic instability and prevented the deterioration of cerebral perfusion in the patient.

Several studies indicate that patients are lost due to profuse bleeding after sternotomy during central cannulation and opening of the pericardium; however, peripheral cannulation compared to the central cannulation can save time and creates a more comfortable surgical field without causing interruption of the cerebral circulation. In the present case, the time elapsed between the beginning of the operation and the commencement of cardiopulmonary bypass was 10 minutes, and the peripheral cannulation allowed for simultaneous initiation of cardiopulmonary bypass once the active bleeding was seen after opening of the pericardium.