A technical pitfall in resuscitative thoracotomy: Delayed mechanical myocardial injury from a narrow pericardiotomy

Mechanical complications related to the configuration of the pericardiotomy during resuscitative thoracotomy (RT) have not been previously documented. No prior report has visually demonstrated a mechanism by which an insufficient pericardiotomy leaves a sharp margin that directly abrades the beating heart.

A 62-year-old man in traumatic cardiac arrest underwent left anterolateral RT and right thoracotomy for hemorrhage control. Pericardiotomy was performed anterior to the phrenic nerve, followed by internal cardiac massage. After temporary closure, he developed recurrent shock 10 h later. CT showed new contrast extravasation along the left ventricular wall. Re-exploration revealed a focal abrasion caused by repetitive contact between a sharp pericardial edge and the beating ventricle. Bleeding was controlled using a fibrin-collagen patch, and the mechanical interaction between the pericardial edge and the left ventricle was resolved by extending the pericardiotomy to the apex. The patient ultimately recovered and was discharged.

This video-documented case demonstrates delayed myocardial injury caused by direct mechanical contact between a narrow pericardiotomy edge and the beating heart, highlighting the need for adequate incision width and attention to pericardial margin during RT.