however , the actual incidence may be higher because many victims may die before arrival at the hospital . with advances in traumatology
, several studies have investigated the prognostic factors associated with traumatic cardiac rupture . in this study
, we attempted to find factors affecting the prognosis of patients with blunt traumatic cardiac rupture .
this retrospective study was reviewed and approved by the institutional ethics committee of our institution ( ethical committee of sungkyunkwan university of samsung changwon hospital , approval number 2015-scmc-037 - 00 ) . between 1999 and 2015 , a total of 107,657 patients were admitted to our hospital due to trauma .
ultimately , we analyzed 21 patients who were diagnosed with blunt traumatic cardiac rupture and required emergency surgery . in our analysis of these 21 patients
all operations were performed via median sternotomy . in each case , cardiopulmonary bypass ( cpb ) or extracorporeal membrane oxygenation was prepared as a precaution . if the patient was hemodynamically unstable , 2 cardiovascular surgeons operated together to perform the median sternotomy and femoral cannulation simultaneously .
after the sternotomy , surgeons opened the pericardium for prompt decompression of the heart , rapidly removed the hematoma , and attempted to find the injury site .
the injury sites were primarily repaired using double - arm monofilament stitches with pledgeted , interrupted sutures .
after the injury sites were primarily repaired , we weaned the patients from cpb as soon as possible .
categorical variables were compared using the chi - square test or the fisher exact test . all p - values < 0.05 were considered to indicate statistical significance .
this retrospective study was reviewed and approved by the institutional ethics committee of our institution ( ethical committee of sungkyunkwan university of samsung changwon hospital , approval number 2015-scmc-037 - 00 ) . between 1999 and 2015 , a total of 107,657 patients were admitted to our hospital due to trauma .
ultimately , we analyzed 21 patients who were diagnosed with blunt traumatic cardiac rupture and required emergency surgery . in our analysis of these 21 patients
all operations were performed via median sternotomy . in each case , cardiopulmonary bypass ( cpb ) or extracorporeal membrane oxygenation was prepared as a precaution . if the patient was hemodynamically unstable , 2 cardiovascular surgeons operated together to perform the median sternotomy and femoral cannulation simultaneously . after the sternotomy , surgeons opened the pericardium for prompt decompression of the heart , rapidly removed the hematoma , and attempted to find the injury site .
the injury sites were primarily repaired using double - arm monofilament stitches with pledgeted , interrupted sutures .
after the injury sites were primarily repaired , we weaned the patients from cpb as soon as possible .
categorical variables were compared using the chi - square test or the fisher exact test . all p - values < 0.05 were considered to indicate statistical significance .
most blunt traumatic cardiac injuries resulted from traffic accidents ( 81% ) , and most patients had combined trauma . the combined trauma included liver laceration , spleen injury , pelvic bone fracture , spinal fracture , and fractures of the extremities ( table 2 ) .
the mean injury severity score ( iss ) was 2817.4 ( range , 16 to 97 ) . among the 21 patients ,
the mean central venous pressure ( cvp ) and systolic blood pressure of the 3 patients who died were 28 cm h2o and 67 mm hg , respectively .
in contrast , the mean cvp and systolic blood pressure of the 7 surviving patients were 26 cm h2o and 81 mm hg , respectively .
three of them had left ventricle injuries , and the other had a right atrium ( ra)/inferior vena cava ( ivc ) junction injury . among these 4 patients ,
therefore , they underwent a co - operation ( open reduction and vessel repair ) to prevent additional bleeding due to systemic heparinization .
the preoperative lab findings , systolic blood pressure , and elapsed time from arrival to surgery are summarized in table 3 .
myocardial band ( ck - mb ) levels ( 13.49.2 ng / ml ) were elevated in most patients .
in contrast , the preoperative creatinine levels ( 1.10.3 mg / dl ) were nearly normal in all patients .
in addition , the mean blood transfusion amount in survivors was 6.3 units , as compared to 9 units in fatalities ( p=0.900 ) .
no instances of intraoperative mortality occurred , but the in - hospital mortality rate was 24% ( 5 of 21 ) .
the causes of death included pneumonia ( 1 ) , inadequate myocardial protection - related low cardiac output ( 1 ) , and massive bleeding - related disseminated intravascular coagulation ( 3 ) .
all fatalities showed liver and renal failure , and 2 of them showed brain death .
significant differences were found in preoperative ck - mb levels ( p=0.042 ) and platelet counts ( p=0.004 ) between the survivors and fatalities .
in addition , the preoperative glasgow coma scale score ( p=0.007 ) , trauma and injury severity score ( p=0.007 ) , and iss were significantly worse in the fatalities than in the survivors ( p=0.004 ) .
no significant differences were found between the two groups in preoperative creatinine levels ( p=0.495 ) or elapsed time to surgery ( p=0.445 ) .
similarly , no significant differences were found in injury location ( p=0.437 ) , cpr history ( p= 0.372 ) , use of cpb ( p=0.182 ) , amount of blood transfusion ( p=0.900 ) , or shock index ( p=0.186 ) between the two groups .
most patients who experience blunt traumatic cardiac rupture die before arrival to the hospital . according to one japanese study ,
91% of patients with blunt traumatic cardiac rupture died within 30 minutes of the accident .
we analyzed 21 patients who experienced blunt traumatic cardiac rupture and compared our results with those of previous studies .
traffic accidents were the most common cause of blunt traumatic cardiac rupture ( 80% ) , and the most common site of injury was the right atrium ( 43% ) [ 2,5,79 ] .
when a patient arrived at the hospital , we first focused on the vital signs , peripheral circulation , presence of an open wound , neck vein distension , and facial plethora .
if cardiac rupture was suspected , we performed chest computed tomography , focused assessment with sonography for trauma , or transthoracic echocardiography as soon as possible . if patients had unstable vital signs , we performed intubation and transfusion , using intravenous inotropics as needed .
if patients had hemopneumothorax , we inserted a chest tube at the emergency department and then rapidly transferred the patients to the operating room .
ten of the 21 patients were suspected to have cardiac tamponade because they had hypotension , high cvp , and echocardiographic signs of tamponade ( the presence of pericardial effusion , diastolic collapse of the right ventricle , ivc dilatation , etc . ) . when we suspected cardiac tamponade , we rapidly moved the patient to the operating room rather than trying to insert a pericardial catheter in the emergency room , because it takes almost the same time to perform a pericardial catheter insertion as to prepare the operating room in our hospital .
the average elapsed door - to - surgery time in patients with cardiac tamponade was 29 minutes .
in contrast , when cardiac tamponade was not suspected , further evaluations were performed prior to surgery .
if a patient s vital signs are unstable , we consider an emergency department thoracotomy to have several advantages , including the prompt decompression of pericardial pressure and the rapid restoration of hemodynamics .
cpb was applied in 4 patients with left ventricular rupture , and in 1 patient with an ra / ivc junction injury .
the overall survival rate was similar to that of a prior study , which found that 70%80% of patients who were transferred to trauma centers survived after blunt cardiac injury .
they found significant differences between survivors and fatalities in preoperative creatinine levels , but no differences in preoperative ck - mb or platelet count .
in contrast , we found no significant difference in preoperative creatinine levels between survivors and fatalities .
in addition , our results revealed significant differences in preoperative ck - mb levels and platelet counts between the two groups .
patients with impaired renal function preoperatively would be expected to have poorer postoperative outcomes than those with normal renal function . in our study , however , all patients had normal preoperative creatinine levels .
this may explain why we did not identify a significant difference between survivors and fatalities .
this enzyme is not specific for cardiac injury , but can reflect severe muscle injury and potentially predict rhabdomyolysis . according to a 1998 study by swaanenburg et al . , among 38 patients with thoracic injuries , 1830 had increased ck - mb levels , increased ck - mb activity , an elevated ratio of ck - mb activity to total ck , or an elevated ratio of ck - mb mass to total ck upon admission .
although elevated ck - mb levels are not specific for cardiac injury , they can be indicative of severe combined injuries and be associated with a poor prognosis .
in addition , a low preoperative platelet count may also be associated with a poor prognosis .
recently reported that the early - stage platelet count was independently related to mortality in blunt trauma patients .
a low platelet count reflects increased platelet consumption as well as massive blood loss and hemodilution . increased platelet consumption can lead to a systemic inflammatory response or disseminated intravascular coagulation .
early platelet consumption can be explained based on the fact that platelet aggregation and blood clot formation begins within 1520 seconds of a major vessel rupture .
we did not find any significant difference in elapsed time from hospital arrival to surgery between fatalities and survivors .
for instance , when a patient was suspected to have cardiac tamponade , surgery was promptly performed within 30 minutes .
this was a case - control study , and case - control studies are prone to bias and confounding .
although we were able to identify some characteristics of survivors , we were not able to clearly confirm causality
. given this limitation , we attempted to identify factors associated with a poor prognosis .
few prior studies have investigated blunt traumatic cardiac rupture due to the rarity of such cases .
we found that elevated ck - mb levels , a low platelet count , and multi - organ traumatic injury were associated with a poor prognosis ( fig .
if a patient with blunt traumatic cardiac rupture exhibits these factors , clinicians should be especially attentive and respond promptly to save the patient s life .
this was a case - control study , and case - control studies are prone to bias and confounding .
the small , heterogeneous study population is a major limitation of this study . although we were able to identify some characteristics of survivors , we were not able to clearly confirm causality
. given this limitation , we attempted to identify factors associated with a poor prognosis .
few prior studies have investigated blunt traumatic cardiac rupture due to the rarity of such cases .
we found that elevated ck - mb levels , a low platelet count , and multi - organ traumatic injury were associated with a poor prognosis ( fig .
if a patient with blunt traumatic cardiac rupture exhibits these factors , clinicians should be especially attentive and respond promptly to save the patient s life .
 backgroundblunt traumatic cardiac rupture is rare . 
 however , such cardiac ruptures carry a high mortality rate . 
 this study reviews our experience treating blunt traumatic cardiac rupture.methodsthis retrospective study included 21 patients who experienced blunt traumatic cardiac rupture from 1999 to 2015 . 
 every patient underwent surgery . 
 several variables were compared between survivors and fatalities.resultssixteen of the 21 patients survived , and 5 ( 24% ) died . 
 no instances of intraoperative mortality occurred . 
 the most common cause of injury was a traffic accident ( 81% ) . 
 the right atrium was the most common location of injury ( 43% ) . 
 ten of the 21 patients were suspected to have cardiac tamponade . 
 significant differences were found in preoperative creatine kinase  
 myocardial band ( ck - mb ) levels ( p=0.042 ) and platelet counts ( p= 0.004 ) between the survivors and fatalities . 
 the patients who died had higher preoperative glasgow coma scale scores ( p=0.007 ) , worse trauma and injury severity scores ( p=0.007 ) , and higher injury severity scores ( p=0.004 ) than those who survived.conclusionwe found that elevated ck - mb levels , a low platelet count , and multi - organ traumatic injury were prognostic factors predicting poor outcomes of blunt cardiac rupture . 
 if a patient with blunt traumatic cardiac rupture has these factors , clinicians should be especially attentive and respond promptly in order to save the patient s life . 
Introduction
Methods
1) Patients
2) Surgery
3) Statistical analysis
Results
Discussion
1) Study limitations
2) Conclusion