Perrotta Sossio, Perrotta Angelo, Lentini Salvatore
Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
Interact Cardiovasc Thorac Surg. 2010 May;10(5):783-92. doi: 10.1510/icvts.2009.226167. Epub 2010 Feb 5.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In patients with sewing needle cardiac injuries is the surgical approach the recommended treatment?' The scientific literature was reviewed by searching Medline, using Ovid interface, from 1950 to August 2009. Six hundred and twenty-six papers were found, of which 24 were deemed relevant to this topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The cause of injury may delay the timing of presentation the diagnosis and consequently the therapeutic strategy. In nearly all the cases in the reviewed papers the authors surgically removed the needle from the heart. However, out of the 24 papers, four patients had a conservative treatment. Most of the authors recommend early removal of the needle to prevent migration and further anatomical damage. The early surgical removal of foreign bodies in the heart is considered an effective approach to prevent complications. The heart is more vulnerable to serious injuries when the foreign body is extracardiac than when the foreign body is completely intracardiac. The unceasing motion of the heart against the sharp point of the fixed foreign body will result in repetitive wounding with bleeding and consequent cardiac tamponade. Due to the tendency of the needle to migrate, the preoperative use of computer tomography scan, trans-thoracic and trans-oesophageal echocardiography have been advocated to locate the exact position of the needle and its correlation with the surrounding tissues. The intraoperative use of epicardial ultrasound or fluoroscopy is also recommended. However, in cases of late diagnosis, in previously untreated patients, treatment can be individualized. If the symptoms are less severe it is reasonable to adopt a conservative approach as with time most foreign bodies become safely encysted and do no harm. Patients can remain asymptomatic for many years. However, they may present many years later with complications such as pericarditis, tamponade or endocarditis. Strict follow-up is useful in those patients.
一篇心脏外科最佳证据主题文章是按照结构化方案撰写的。所探讨的问题是：“对于缝针所致心脏损伤患者，手术入路是否为推荐的治疗方法？”通过使用Ovid界面检索1950年至2009年8月的Medline对科学文献进行了回顾。共找到626篇论文，其中24篇被认为与该主题相关。将这些论文的作者、期刊、出版日期和国家、所研究的患者群体、研究类型、相关结局和结果制成表格。损伤原因可能会延迟就诊时间、诊断以及相应的治疗策略。在所回顾论文的几乎所有病例中，作者均通过手术从心脏取出了缝针。然而，在这24篇论文中，有4例患者接受了保守治疗。大多数作者建议尽早取出缝针以防止其移位和进一步的解剖损伤。早期手术取出心脏内异物被认为是预防并发症的有效方法。当异物位于心脏外时，心脏比异物完全位于心脏内时更容易受到严重损伤。心脏持续抵靠固定异物的尖端运动会导致反复创伤并出血，进而引发心脏压塞。由于缝针有移位的倾向，有人主张术前使用计算机断层扫描、经胸和经食管超声心动图来确定缝针的确切位置及其与周围组织的关系。术中也建议使用心外膜超声或荧光透视检查。然而，对于诊断较晚的既往未治疗患者，治疗可个体化。如果症状较轻，采取保守方法是合理的，因为随着时间推移，大多数异物会安全地被包裹起来且无害。患者可能多年无症状。然而，他们可能在多年后出现心包炎、心脏压塞或心内膜炎等并发症。对这些患者进行严格随访很有用。
