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Ann Thorac Surg 2001;71:1714-1715
© 2001 The Society of Thoracic Surgeons

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How to do it

The use of adenosine for repair of penetrating cardiac injuries: a novel method

^a Department of Cardiothoracic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^b Department of Cardiothoracic Anesthesia, MetroHealth Medical Center, Cleveland, Ohio, USA

Accepted for publication December 28, 2000.

^* Address reprint requests to Dr Gill, Department of Cardiothoracic Surgery, The Cleveland Clinic Foundation, Hamann Building, 3rd Floor, 2500 MetroHealth Dr, Cleveland, OH 44109-1998 (Email: gillis{at}ccf.org).

	Abstract

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The use of intravenous administration of adenosine to expedite cardiorrhaphy in penetrating cardiac trauma by inducing temporary asystole is described. It is quicker, more effective, and safer than the traditional methods.

	Introduction

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The repair of penetrating cardiac injuries has been the subject of several reports [1–3]. Here, we describe the use of intravenous administration of adenosine to cause temporary asystole to allow easy and accurate placement of sutures for a left ventricular laceration.

	Technique

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A 29-year-old man was stabbed in the chest with a kitchen knife. At the scene, the patient was noted to be hypotensive with a palpable systolic blood pressure of 65 mm Hg and to have diminished heart sounds and breath sounds over the left chest. Fluid resuscitation was started, and the patient was transported to our trauma center. On arrival, he was both unresponsive with shallow respiration, and hypotensive with a barely palpable pulse, and he had diminished heart and breath sounds on auscultation. Heart rhythm was agonal. An entry wound measuring approximately 5 cm was noted at the fourth intercostal space along the left anterior axillary line.

The patient was intubated, and a left thoracotomy was performed in the emergency department. The pericardium was found to be tense and was opened. After release of the tamponade, the patient’s hemodynamic status improved. On further examination of the heart, an entry wound in the left ventricular lateral wall measuring 2.5 cm was revealed. The bleeding was controlled by direct pressure, and the patient was rushed to the operating room. Heart rate was 130 beats per minute, and blood pressure was 80/50 mm Hg. A 12-mg intravenous bolus of adenosine (Adenocard) was injected into an 8F central trauma line inducing temporary asystole for a few seconds to allow accurate placement of 3-0 Teflon felt-pledgeted stitches (Ethicon Inc, Somerville, NJ) on the laceration in the left ventricle. The dose was repeated once. After the hemorrhage was controlled, the patient’s vital signs improved. Two chest tubes were placed, and the thoracotomy was closed. Postoperatively, except for confusion and short-term memory loss, the patient had an unremarkable clinical course and was transferred to a rehabilitation facility.

	Comment

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Suture techniques for penetrating cardiac injuries range from simple interrupted sutures, with or without Teflon felt pledgets, to simple running or mattress sutures [1–3]. These methods require the surgeon to digitally occlude the laceration while placing multiple sutures. The needle is passed under the finger with each stitch. This process is often difficult to perform because of the movement of a beating heart and the risk of cutting through the tissues and sustaining a needle-stick injury. Cardiopulmonary bypass with cardioplegic arrest can also be used, especially for multichamber injuries [1–3]. Recently some centers have advocated the use of skin staples as a temporary measure to control cardiac wound hemorrhage, especially in the emergency room [4]. Total inflow occlusion can also be employed to achieve control of bleeding, but this cannot be sustained in a patient who is already in hemodynamically unstable condition. We report the use of adenosine to cause temporary asystole to allow the surgeon to accurately place the sutures expeditiously, thereby effectively controlling the hemorrhage.

Adenosine is a purine nucleoside occurring in all cells of the body. A rapid bolus of intravenously administered adenosine produces acute inhibition of sinus node and atrioventricular node function, which can result in sinus bradycardia, transient atrioventricular block, and asystole [5]. These short-lived electrophysiologic effects have made adenosine an effective agent for restoring sinus rhythm in patients with supraventricular tachycardia [5] or for unmasking atrial tachyarrhythmias or ventricular preexcitation. Lately, adenosine has also proved to be a cardioprotective agent because of its coronary dilating effect [6] and its role in mediating ischemic preconditioning in patients undergoing off-pump coronary artery bypass grafting [7, 8]. It could also be used to facilitate accuracy in controlling conventional graft anastomotic bleeding.

The usual bolus dose of 6 to 12 mg of adenosine (0.15 to 0.3 mg/kg) should be rapidly injected through a large-bore central intravenous catheter and can be repeated. This low dose is sufficient to achieve temporary asystole within 30 seconds of injection and gives the surgeon time to do the repair on a motionless heart. Owing to adenosine’s ultrashort half-life, the asystolic period lasts for only a few seconds (15 to 20 seconds in our patient) with restoration of sinus rhythm afterward. When larger doses are given by infusion, adenosine lowers blood pressure by decreasing peripheral resistance. Phenylephrine hydrochloride can be given to expedite blood pressure recovery. Adverse effects consisting of flushing (44%), chest discomfort (40%), dyspnea (28%), headache (18%), first- and second-degree atrioventricular block (3%), and hypotension (2%) are dose related and usually resolve quickly once the drug is discontinued [6]. Rarely, acute bronchospasm can occur [9]. A full monitoring system, pacing backup, corrective measures for control of unwanted hemodynamic effects, and a safety net defibrillator system were available during the entire operation.

Because of the rapid onset and brief duration of action of adenosine, its intravenous administration during repair of penetrating cardiac injuries is safe and effective. Because adenosine causes temporary asystole, the surgeon has ample time to accurately place the required number of sutures in a semibloodless field and adequately control the hemorrhage.

	Addendum

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Since the submission of this manuscript, a second penetrating cardiac injury, this one caused by a gunshot wound through the left ventricular free wall, was successfully managed through a sternotomy by intravenous administration of adenosine.

	References

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1. Asencio JA, Stewart BM, Murray J, et al. Penetrating cardiac injuries Surg Clin North Am 1996;76:685-724.[Medline]
2. Wall MJ, Mattox KL, Chen CH, et al. Acute management of complex cardiac injuries J Trauma 1997;42:905-912.[Medline]
3. Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries Ann Thorac Surg 1991;51:711-716.[Abstract/Free Full Text]
4. Mayrose JM, Jehle DV, Moscati R, Lerner EB, Abrams BJ. Comparison of staples versus sutures in the repair of penetrating cardiac wounds J Trauma 1999;46:441-444.[Medline]
5. Adenosine. In: Mosby’s GenRx—drug information. 9th ed. St. Louis: Mosby, 1999;II42.
6. Wilson RF, Wyche K, Christensen BV, et al. Effects of adenosine on human coronary arterial circulation Circulation 1990;82:1595-1606.[Abstract/Free Full Text]
7. Gill IS, FitzGibbon GM, Higginson LAJ, Valji A, Keon WJ. Minimally invasive coronary artery bypass. a series with early qualitative angiographic follow-up. Ann Thorac Surg 1997;64:710-714.[Abstract/Free Full Text]
8. Robinson MC, Thielmeier KA, Hill BB. Transient ventricular asystole using adenosine during minimally invasive and open sternotomy coronary artery bypass grafting Ann Thorac Surg 1997;63:530-534.
9. Bennet-Guerrero E, Young CC. Bronchospasm after intravenous adenosine administration Anesth Analg 1997;79:386-388.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Inderjit S. Gill Charles E. Smith Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lim, R. Articles by Smith, C. E. Search for Related Content PubMed PubMed Citation Articles by Lim, R. Articles by Smith, C. E.