1. Introduction

Surgery of heart wounds has undergone significant changes in its history. In the XIX century, they did not risk taking on such a type of surgery, given the 100% lethality rate. For example, one of the great surgeons of the XIX century T. Billroth said in 1883 "... A surgeon who would try to sew up a heart wound would lose all respect of his colleagues...." [1]. High mortality, the inability to correct or stabilize life–threatening complications in heart injuries in any way - all it logically served as a reflection of the thesis of the doom and senselessness of surgical intervention in such severe type of patients. Subsequently, the concept of managing the victims changed – if those patients were taken to the clinic, then they had to not only be operated on, but also survive [2,3].

The outcome of the treatment of heart penetrating wounds directly depends on the timely diagnosis of life-threatening complications and the effective elimination of existing injuries [4]. Cardiogenic shock, cardiac tamponade and other dangerous complications need to be eliminated as soon as possible. As a rule, these complications are developed immediately after injury. It is the reason for a significant time limit in providing timely medical care to the victim directly at the scene and at the hospital stage [5]. In this regard, timely diagnosis of the presence of a heart injury at the prehospital stage with the delivery of patients to emergency surgery departments is of great importance in the treatment outcome of these patients [6].

There is no unambiguous solution to the problem of diagnosing and treating heart injuries, despite the improvement in the organization of emergency medicine, the development of technology and the capabilities of surgical interventions, anesthesiology and resuscitation services, and a large arsenal of instrumental diagnostics in large medical institutions at the present stage of development of medicine [7]. According to literature data, the hospital mortality rate for heart wounds reaches 60%, and in cases of penetrating heart wounds – up to 90%, and this trend does not decrease [8].

The above data serve as an objective justification for the need for further research on the development of a new therapeutic and diagnostic algorithm for heart injuries with the identification of priority methods for diagnostics and treatment.

The aim of the study was to improve the diagnostics and surgical treatment results of heart wounds in chest injuries by improving the therapeutic and diagnostic algorithm.

2. Material and Methods

The study was based on the analysis of the diagnostics and treatment results of 112 patients with heart wounds at open chest injuries, which we observed in the surgical departments of the Republican Research Center of Emergency Medicine and its branches for the period from 2010 to 2021. Depending on the tactics and method of treatment and diagnostic procedures, all patients with heart injuries were divided into 2 groups: control and main. The control group included 59 (52.7%) patients who were used traditional therapeutic and diagnostic tactics. The main group consisted of 53 (47.3%) patients in whom the therapeutic and diagnostic process was supplemented by the extensive use of modern methods of radiation imaging, the use of minimally invasive treatment methods, as well as an improved scheme of conservative therapy in the postoperative period. The exclusion criteria from the research groups were the absence of damage to the structures of the heart during penetrating injury of the chest organs, regardless of a complex use of diagnostic research methods and minimally invasive surgical interventions. The inclusion criteria in the control group were the presence of injury to the structures of the heart, detected during surgery, regardless of the presence or absence of damage to other organs (lungs, ribs, diaphragm, abdominal organs, etc.). The inclusion criteria in the main group, in addition to intraoperatively detected injury of cardiac tissue, were the use of minimally invasive therapeutic and diagnostic interventions (MSCT, videothoracoscopy), as well as the use of cardioprotective drugs in the postoperative period.

The research groups were representative by age, gender, underlying pathology and its complications, and concomitant pathology. They differed in the therapeutic and diagnostic tactics used for the correction of heart wounds. There were 77 (68.7%) males and 35 (31.3%) females. The mean age of the patients was 32.5 ± 3.9 years. At the same time, 53.6% of patients were at the most able-bodied age (from 18 to 60 years).

3. Results

Our studies revealed the following: 69.0% of patients were transported by ambulance; bystanders brought 31.0% victims without providing any medical assistance. At the prehospital stage, victims admitted by ambulance or referral were provided with first aid in the form of administration of painkillers (62.5%), infusion therapy (57.1%), and artificial ventilation (32.1%).

58.0% of patients admitted in the first “golden” hour, from one to three hours - 32.1% of victims. 9.8% of patients admitted from three to six hours from the moment of injury. The most frequent mechanism of injury in the examined patients was criminal (60.6%), the second one was industrial (31.3%). The number of patients with domestic injuries was relatively smaller and made up (8.1%).

According to the nature of the heart injuries, 22 (19.7%) patients had non-penetrating wounds, and 79 (70.5%) patients had wounds penetrating into the heart cavity. At the same time, 7 patients with non-penetrating wounds of the heart we observed an injury to the pericardium, and in 15 cases - to the myocardium.

The study of the localization of the heart penetrating wounds showed that the most numerous group consisted of victims with injuries to the left ventricle (70.5%) and right atrium (18.7%). The number of patients with injuries of the right ventricle (2.7%) and left atrium (1.8%) was slightly lower. 11 patients had multiple heart injuries, which were accompanied by damage to coronary vessels (4.4%), elements of the conducting system (3.6%) and various heart valves (1.8%).

In 23 patients with heart injuries in the control and main groups there were no clinical signs of cardiac tamponade. In contrast, in 89 patients, clinical signs of cardiac tamponade accompanied heart injuries. Moreover, if 38 patients had stage I tamponade with the presence of blood in the cardiac membrane up to 250.0 ml, then 51 patients had stage II tamponade - when there was more than 250.0 ml of blood in the cardiac membrane.

In 61 (54.5%) from 112 patients with cardiac injuries, a serious condition was observed upon admission due to the presence of cardiogenic shock and blood loss of varying degrees. Thus, 31 (27.7%) patients in the control group and 30 (26.8%) in the main group had grade II-III shock and blood loss with a deficit in circulating blood volume (CBV) from 20 to >30%. In this regard, the general condition of these patients was estimated as severe and extremely serious. Along with this, 28 (25.0%) victims of both groups had grade I cardiogenic shock, blood loss with a CBV deficiency up to 20%. We regarded the general condition of this type of patients as of moderate severity. Due to the absence of shock and blood loss signs, the overall condition of 23 patients with heart injuries was correlated to satisfactory. 91 (81.3%) patients admitted to the clinic with various degrees of impaired consciousness.

All patients with heart injuries were examined urgently. The diagnostic process, when available to the contact, began with clarifying patients' complaints and collecting anamnesis. In parallel, a rapid physical examination was carried out using the methods of questioning, examination, palpation, auscultation, percussion. In all examined patients with cardiac injuries, we noted the phenomenon of their mutual aggravation with existing other injuries to the structures and the chest organs (pleura, lungs, diaphragm, etc.), regardless of their adjacent significance. In addition, we carried out recognition of cardiac injuries in the examined patients with open chest injuries under conditions of acute time shortage (“golden hour”) determined by the severity of the injury.

In connection with these circumstances, as well as based on the experience of the Republican Research Center of Emergency Medicine, the diagnostic process of heart injuries in organizational terms was strictly regulated by us and subjected to the following basic principles:

• simultaneous, fastest possible implementation of all diagnostic procedures to identify the presence of heart wounds and other injuries to the organs of the chest cavity;

• combination of an active diagnostic process with treatment of all life-threatening phenomena associated with cardiac injury;

• timely performance of surgeries in order to correct the existing heart injury;

• prevention and treatment of vital functions disorders and complications.

According to these principles, diagnostic studies in patients with heart injuries with unstable hemodynamics and II-III degree of shock were carried out on the operating table, during anti-shock measures and surgical intervention. In them and in patients with stable hemodynamics, polypositional X-ray and chest X-ray, and echocardiography (Echo-KG) were used in the diagnostic process. 142 chest X-ray examinations were performed in 102 (91.1%) patients with heart injuries. In addition, 23 patients were performed MSCT of the chest organs.

Reliable radiological verification of penetrating cardiac injury was the identification of various signs of cardiac tamponade in 89 patients (81.7%). An increase in the cardiac shadow we observed in all 89 patients with cardiac tamponade. Due to an increase in the cardiac shadow, in 81 patients there was a predominance of the diameter of the heart over its length, which was also a sign of tamponade. Radiological signs of cardiac tamponade also included the spherical shape of the cardiac shadow and smoothness along the contours of the cardiac shadow, established in 52 and 46 examined patients of both groups, respectively. Along with this, in 34 patients we identified another sign of cardiac tamponade in the form of impaired myocardial contractility. It should be noted that all these signs of cardiac tamponade in 48 patients were accompanied by x-ray detection of the presence of hemothorax: in 32 cases - small, in 11 – medium and in 5 cases – large.

Chest radiography in 18 patients revealed fractures of the ribs and sternum with the development of pneumothorax with collapse of the lung in 12 cases - by 1/3 of the volume, and in 4 cases - by 2/3 of the volume. In two cases, pneumothorax was total. In 11 patients pneumothorax was combined with hemothorax. At the same time, the ratio of blood and air amount in the pleural cavity was different. In 28 patients, a plain chest x-ray revealed a high position of the diaphragm, which in nine cases was accompanied by limited respiratory excursion on the side of the injury. This indicated the presence of damage to the diaphragm and the abdominothoracic nature of the chest injury. In 23 patients, MSCT showed a picture of hemopericardium of varying severity. In addition, 14 patients had a picture of hemothorax, 9 patients had rib fractures, and 3 patients had damage to the diaphragm. The next instrumental research method in the examined patients with cardiac injuries was echocardiography (Echo-CG). Echo-CG in our studies was performed on 62 patients in the control and main groups.

Among the echocardiographic signs of cardiac injuries in the examined patients, the most reliable and frequently detected was the determination of fluid in the pericardial cavity, which was established in 56 (90.3%) of the examined patients. Along with this, during Echo-CG, we identified additional symptoms that were a unique manifestation of the main echocardiographic signs of heart injuries. In 2 (3.2%) patients, the presence of blood in the pericardial cavity was combined with a decrease in the degree of collapse of the inferior vena cava walls at the height of deep inspiration. In addition, in 7 patients (11.3%) with cardiac injuries, echocardiography revealed shunting of blood from left to right, which was associated with the presence of a septal defect.

Changes associated with the QRST complex were observed among the ECG signs in the examined patients with heart injuries, namely a sharp decrease in wave voltage - (41.9%). 24.1% of patients had a cardiac impulse conduction disorder. Changes in the T wave were noted in the form of its inversion in 28.6% of cases. Along with the above changes, in 42 (37.5%) patients with cardiac injuries, we recorded various cardiac arrhythmias on the ECG. In 6.2% of patients with heart injuries, we detected complete transverse blockade on the ECG.

We applied traditional treatment tactics to all patients with cardiac injuries in the control group (n=59). At the same time, correction of existing cardiac injuries was mainly carried out through traditional thoracotomies, sternotomies and their combinations. At the same time, they were performed traditional surgical correction of other existing injuries of the chest organs.

In contrast, we used optimized treatment tactics in 53 patients of the main group. Minimally invasive interventions in the form of videothoracoscopy were widely used in patients of the main group at the diagnostic stage, which in 14 cases allowed detecting the presence of heart injury signs. Subsequently, a mini-thoracotomy was performed to eliminate the existing injuries. Traditional thoracotomies, sternotomies and laparotomies in the main group were forced to be used only in patients with severe conditions and unstable hemodynamics. In contrast to the control group, correction of all existing associated injuries in patients of the main group (suturing of lung wounds, fixation with rib fractures, and removal of clotted hemothorax) was carried out using minimally invasive methods.

In addition, in the main group of patients, in order to correct the functional state of the injured myocardium in the postoperative period, traditional conservative therapy was supplemented by the administration of antioxidant and antihypoxic drugs.

In the control group, postoperative complications were observed in 44.1% of patients, in the main group - in 22.6% cases. At the same time, there was a significant reduction of patients' hospital stay: the average number of bed days in the control group was 24.8+2.4, and in the main group - 12.8+1.3 days. In the main group, the lethal outcome was observed in 3 patients, in the control group – in 15 ones.

4. Discussion

Bystanders to our clinic brought about a third of the victims without providing the necessary primary medical care, which significantly affected the severity of the patients' condition and the subsequent prognosis of treatment. The time of patients’ delivery was of great importance, which directly affects the volume of blood loss and the severity of shock. The penetrating nature of heart wounds significantly aggravates the condition of the injured due to the rapid development of life-threatening complications in the form of cardiac tamponade, damage to intracardiac structures, massive blood loss and asystole. In our studies, the proportion of penetrating wounds was more than 3 times higher than the number of non-penetrating ones, which emphasized the importance of timely and well-coordinated work of the medical team.

Patients of the control and main groups with a heart injury in accordance with the rule of the "golden hour" were taken to the emergency shock department, where a responsible surgeon, anesthesiologist-resuscitator, thoracic surgeon and cardiologist examined them. In parallel, during the first 15 minutes, measures to ensure the preservation of vital functions of the body (stopping external bleeding, restoring/maintaining patency of the upper respiratory tract, oxygen therapy, tracheal intubation and artificial ventilation of the lungs according to indications, cardiopulmonary resuscitation, catheterization of the main veins and bladder, initiation of infusion-transfusion antishock therapy, anesthesia) were taken. Each of the specialists solved their professional tasks, the overall management and a responsible surgeon from among the most trained specialists carried out interaction of the team at the first stage.

Patients with stable hemodynamics had the opportunity to conduct a whole range of diagnostic studies to identify signs of heart injury. The signs of cardiac tamponade were revealed in 81.7% of X-ray examination cases.

In terms of detecting blood in the pericardial cavity, echocardiographic examination had a high sensitivity, which amounted to 90.3% of reliably positive results.

Unfortunately, despite the rather high informativeness of the Echo-KG, this research method has some disadvantages. Our studies have shown that in certain clinical situations the information content of Echo-CG is reduced. It was due to the negative impact of the presence of concomitant hemothorax or pneumothorax in patients, which led to an increase in the number of false-negative results of Echo-CG and caused an unjustified delay in establishing the diagnosis of cardiac injury in 9.7% of patients.

Special importance was attached to an ECG study among the traditional methods of diagnosing heart injuries, which allowed to assess the functional state of the myocardium. We performed an ECG in all the examined patients, and in some cases - several times, for evaluating the efficiency of the treatment.

It should be emphasized that at the instability of central hemodynamics and the serious condition of patients, surgical interventions in 27 patients of the control and main groups for vital indications were performed urgently in the form of traditional thoracotomy. Moreover, this contingent of patients needed preliminary preoperative preparation: replenishment of CBV, restoration of acid-base balance, water-electrolyte balance, detoxification therapy, which was carried out in a short time – up to 2-4 hours.

The traditional interventions used in patients with heart injuries in the form of traditional thoracotomy, sternotomy or a combination of them, for all their validity, are traumatic and cause a large number of postoperative complications and high mortality rates.

In contrast, modern minimally invasive technologies in the form of video thoracoscopy with mini-thoracotomy, due to their simultaneous adequacy and minimally invasive nature, significantly reduce the traumatism and violence of interventions in patients with heart injuries. Therefore, these methods are more effective than traditional treatment.

The inclusion of antioxidant drugs in the optimized scheme of conservative therapy significantly increases its ability for the correction of existing metabolic disorders in the cardiomyocytes of the injured heart in the postoperative period. It helps to improve the processes of restoration of damaged cardiomyocytes, wound healing on the myocardium and functional rehabilitation.

The above conclusions on the diagnostics and treatment of patients with heart injuries were the basis for the development of a new therapeutic and diagnostic algorithm that is the most complete and meets the requirements of emergency surgery of heart wounds. We have received a patent for this diagnostic and treatment algorithm for the program of electronic computers No. DGU 22712, Intellectual Property Agency under the Ministry of Justice of the Republic of Uzbekistan dated by 2023 (Fig. 1).

Figure 1. Algorithm for diagnostics and selection of surgical treatment tactics in patients with suspected heart injury

5. Conclusions

Comparison of treatment results of patients with heart injuries in the control and main groups indicated that traditional interventions in patients with heart injuries were more traumatic, which lead to a greater number of postoperative complications and high mortality rates.

The introduction of minimally invasive technologies and an optimized scheme of postoperative conservative therapy into the therapeutic and diagnostic protocol of heart wounds optimized the therapeutic and diagnostic process and significantly improved the treatment results of this heavy contingent of urgent patients. It was manifested by a decrease in the number of postoperative complications, in reducing of mortality and a decrease of patients' hospital stay.

The wide application of the developed treatment and diagnostic algorithm in the surgical departments of RRCEM, its regional and district branches, in our opinion, optimizes the therapeutic and diagnostic process and significantly improves the treatment results of this heavy type of urgent patients.

The authors declare no conflict of interest.

This study does not include the involvement of any budgetary, grant or other funds.

The article is published for the first time and is part of a scientific work.