A 59-year-old man with self-inflicted penetrating chest trauma was admitted in our hospital. He tried before to commit suicide hanging himself with a rope, as the signs on his neck revealed. The patient arrived on mechanical ventilation. His blood pressure was 90/50 mmHg, the heartbeat was 92 bpm and haemoglobin was 10.8 mg/dl. On clinical examination, the patient had still the knife into his body (Figure 1-1) with whole blade inflicted just below the xiphoidal process, leaving outside only the knife handle. Pre-operative computed tomography (CT) scan showed critical proximity between the knife blade and the right ventricle (Figure 1-2) so suspecting a right ventricle injury arterial femoral cannulation for cardiopulmonary bypass was achieved. A median sternotomy was performed, the pericardium was longitudinally opened draining about of 500 ml of haematic fluid and the knife was safely removed (Figure 1-3). Intraoperative findings showed pericardial and diaphragmatic lesions with heart and abdominal organs integrity (Figure 1-4). The diaphragmatic lesion showed an active bleeding into the mediastinum. A direct suture of the diaphragm muscle was not possible because of the huge laceration and the friable edges so the diaphragm muscle was repaired with a CorMatrix  patch (Figure 1-5). Chest drain tubes were placed and the sternum was closed with interrupted steel wires. Despite the diaphragmatic surface has been increased in order to repair the muscle itself, patient's gas exchanges were not affected. The patient, in fact, was extubated the day after surgery. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day, after a psychiatric consulting.