Management of the Wounded Heart

Forty-five patients underwent operation for wounds which had penetrated the pericardium. The preoperative diagnosis was cardiac tamponade in 36 patients and hemorrhagic shock in 9. Cardiac tamponade was often difficult to diagnose—the paradoxical pulse was not clinically useful, and central venous pressure frequently was falsely elevated. Pericardiocentesis was performed in 18 patients with 7 false-negative and 3 false-positive results. A preliminary subxiphoid pericardial window was done in 21 patients. Technical adjuncts included inflow occlusion, electrical fibrillation, partially occluding clamps, and stabilizing traction sutures. Cardiopulmonary bypass was not used. The current incision of preference is a median sternotomy to allow a preliminary subxiphoid pericardial window to be performed in patients with tamponade and a thoracotomy if there is massive bleeding into the pleura.