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Stapled Cardiac Repair

Lance Stuke lstuke at yahoo.com
Fri Dec 18 01:15:11 GMT 2009


I don't think there's good data either way. The only recent study I'm aware of was in JOT in 1999 - comparing stapled repair vs suturing of cardiac lacerations in animal hearts (porcine? I can't remember). Tensile strength was equal between the two techniques in that study. 

I had some free time this afternoon so I went back to the books, so to speak, and reviewed some textbooks in my office and in my partner's offices to see what the consensus is among several authors. Here's an unofficial review:

Trauma, 6th ed (Feliciano, Mattox, Moore) - atrial inj: primary suture repair without plegets. Ventricular injury: +/- pledgets depending on the degree of injury

Trauma Surgery (Moylan): advocates the use of pledgets

War Surgery (Husum) - atrial inj: running repair, no pledgets. Ventricular inj: pledgets (they specifically mentioned using pericardial tissue)

Textbook of Penetrating Trauma (Ivatury, Cayten)- atrial inj < 1cm: horizontal mattress or running primary repair. Atrial inj > 1cm: pledgets. Ventricle: pledgets

Atlas of Trauma (Thal, Carrico, Weigelt): suture repair; pledgets advocated only in cases of destructive injury (chapter written by Dr Mattox)

ATOM textbook - pledgets
Additionally, they have a picture of a stapled repair which has been reinforced by pledgets, so that may be the answer to the original question that was posed by Dr. Sise

As you can see, there's no consensus about this issue among some of the best minds in the trauma community. 

I prefer to use pledgets. I don't do elective cardiac surgery, so the only time I operate on the heart is in the trauma setting. I don't want to risk tearing cardiac tissue and need all the extra advantages I can get. Hope this helps. 

Lance

Lance Stuke, MD, MPH
Spirit of Charity Trauma Center
Assistant Professor of Surgery
LSU Department of Surgery
New Orleans, LA




--- On Thu, 12/17/09, McSwain, Norman E <nmcswai at tulane.edu> wrote:

> From: McSwain, Norman E <nmcswai at tulane.edu>
> Subject: Re: Stapled Cardiac Repair
> To: trauma-list at trauma.org
> Date: Thursday, December 17, 2009, 10:32 AM
> Is there evidence that it is wrong to
> use them? I have not seen any such reports. This sounds like
> principle vs preference to me. But I would love to see some
> data
> 
> Norman
> 
> Typed by the thumbs of
> Norman on his BlackBerry 
> 
> Norman McSwain, MD
> Tulane Univ Surgery
> 504 988-5111
> 
> ----- Original Message -----
> From: trauma-list-bounces at trauma.org
> <trauma-list-bounces at trauma.org>
> To: 'trauma-list at trauma.org'
> <trauma-list at trauma.org>
> Sent: Thu Dec 17 07:31:25 2009
> Subject: Re: Stapled Cardiac Repair
> 
> I use pledgets and have since training with Spencer and
> crew @ NYU.  Furthermore the ATOM text recommends their
> use - based on the almost universal consensus of over 40
> trauma surgeons who read, critiqued and/or wrote the
> text.  Urban legend perhaps, but one that has survived
> admittedly in the absence of Class I evidence!
> Ron
> Typed (poorly) with my thumbs on my Blackberry!
> 
> ----- Original Message -----
> From: trauma-list-bounces at trauma.org
> <trauma-list-bounces at trauma.org>
> To: trauma-list at trauma.org
> <trauma-list at trauma.org>
> Sent: Thu Dec 17 07:51:48 2009
> Subject: RE: Stapled Cardiac Repair
> 
> > Now my question 1.   When and why did
> the use of pledgets  
> > begin? 
> 
> Two possiblities: 
> 1. Emil A. Naclerio. Penetrating Wounds of the Heart. Dis
> Chest 1964;46;1-22. A paper worth reading for anyone with an
> interest. In it he suggests that pledgets may rarely be
> needed and add a margin of safety. This could have been
> translated over the years to "if you're worried about it,
> use pledgets".
> 2. Dwight E. Harken who was one of the great pioneers of
> cardiac trauma surgery during the Second World War. As I
> understand it, he tended to use pledgets in his later
> general surgical practice, so we may have had a generation
> of surgeons with an interest in trauma being taught cardiac
> surgery by him and learning to use pledgets.
> 
> Like much of what we do, the origins are not clear, and a
> RCT looking at use of pledgets in cardiac injury is
> unlikely.
> 
> Matt Dunn
> 
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