Selective non-operative management of a left ventricular pse
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Post-traumatic cardiac pseudoaneurysm (PSA) is a rare, potentially life-threatening complication following penetrating cardiac injury. Early prophylactic surgical aneurysmectomy has been the treatment of choice. However, in small and stable postinfarct PSA selective non-operative management (SNOM) has been practiced. [1] We report a case of a post-traumatic cardiac PSA subjected for SNOM. A 38-year-old Hispanic male was admitted to Los Angeles County + University of Southern California Medical Center after sustaining a single stab wound to the left chest. Upon arrival the patient was bradycardic with a systolic blood pressure of 50 mmHg, and Glasgow Coma Scale (GCS) score of 3. The patient underwent simultaneous intravenous access, oral intubation and resuscitative left thoracotomy. After evacuation of 400 ml of blood and clot from the chest a pericardial wound was noted anterior to the phrenic nerve. The cardiac tamponade was rapidly decompressed and cardiac arrest was noted. A cardiac wound in the left ventricle was repaired using a 2.0 polypropylene suture. An aortic cross-clamp was applied. Cardiac massage along with intracardiac injection of epinephrine and bicarbonate resulted in sinus tachycardia. Four additional sutures were required upon restoration of sinus tachycardia to control an exsanguination in the emergency department as the full extent of the defect was not evident during asystole. Residual hemorrhage was present when the patient was taken to the operating room (OR) for definitive repair. In the OR, the cardiac wound was reinforced with four pledgeted polypropylene mattress sutures with no residual hemorrhage. Nevertheless, the left ventricular wall appeared edematous and bruised after the complex repair. The pericardium was left open. The patient continued to be hypothermic, acidotic and coagulopathic. Attempted chest closure resulted in severe bradycardia and therefore, temporary closure was obtained with a vacuum-assisted closure device and the patient was transferred to the surgical intensive care unit....;year=2012;volume=5;issue=4;spage=353;epage=355;aulast=Talving