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Lopez-Marco et al. Vessel Plus 2018;2:40 I http://dx.doi.org/10.20517/2574-1209.2018.67 Page 3 of 6

Figure 1. Preoperative CT scan of thorax and abdomen. Coronal view showing a localized collection in the inferior/posterior pericardial walls

cannulation and mild hypothermia was established. Myocardial protection was achieved with intermittent
antegrade cardioplegia.

Following a right atriotomy, visualisation of the septum was achieved through the tricuspid valve (TV); there
was a 3 cm VSD just below the posterior leaflet of the TV, which was detached due to complete transection
of the papillary muscle head.

The VSD was closed with interrupted non-absorbable sutures reinforced with teflon. The papillary muscle
head was re-implanted with a goretex suture. The TV was tested with saline test confirming competency.
Closure of the right atrium was performed with a continuous 3/0 prolene suture as well as the injury on the
inferior wall of the RV using a continuous 3/0 prolene suture reinforced with 2 bands of teflon.

The patient was successfully removed from CPB. However the intraoperative TOE identified severe MR
secondary to a new prolapse of A2 segment (or the central scallop of the anterior leaflet) with a flail
chordae, which was probably partially ruptured and the complete transection occurred within the de-airing
maneuvers [Figure 2C].

CPB was reinstituted and the left atrium (LA) was opened confirming the mitral aetiology; repair was
performed with implantation of a goretex neochardae and a 30 mm physio II ring annuloplasty. The LA
was closed and the CPB was weaned easily with good results of the repairs confirmed on TOE and with no
residual interventricular shunt. After a long period to secure haemostasis, the chest was closed routinely
after placing one mediastinal and one pericardial drains.

The postoperative period was satisfactory, being discharged by day 10 when the levels of oral anti-
coagulation were satisfactory. Follow-up visit at 6 weeks confirmed that he was asymptomatic and in sinus
rhythm. The echocardiography confirmed a good result of the repairs, with trace TR, no MR and no residual
VSD. The left and right ventricular functions were preserved with residual inferior hypokinesis of the RV.

DISCUSSION
Penetrating chest trauma, usually due to stab or gunshot wounds, can produce a wide variety of cardiac
[2]
injuries which are life threatening in most cases. The mortality at the scene has been reported as high as 80% .