- Exposure
- Perform a left anterolateral thoracotomy, extend across the sternum (clamshell) if more exposure needed
- Open pericardium vertically anterior to phrenic nerve
- Retract or incise further for exposure of injury site
- Control of bleeding
- Apply digital pressure or place a Foley catheter into the wound and inflate to control bleeding temporarily
- Use skin stapler as a temporising measure on linear lacerations if suturing is delayed
- Definitive repair
- Use non-absorbable monofilament suture (e.g. 3-0 or 4-0 polypropylene) on a Pledgeted needle
- Close linear wounds with interrupted horizontal mattress sutures with pledgets to prevent tearing through the myocardium
- Avoid deep bites near coronary vessels — shallow, controlled suture placement
- For small ventricular wounds: may use figure-of-eight or horizontal mattress
- For right ventricle: take extra care due to thin wall and risk of tearing
- For atrial wounds: delicate repair with finer suture and small pledgets
- Adjuncts and closure
- Ensure haemostasis before closing pericardium loosely or leaving it open if oedema is expected
- Place pericardial or mediastinal drain if indicated
- Close chest in standard layers if patient is stable
- Post-op considerations
- Monitor for arrhythmias, tamponade, or myocardial dysfunction
- ICU care with inotropes if required
- Serial echocardiography to assess repair integrity