I. History Penetrating cardiac injuries were generally considered to be incurable until the late nineteenth century, when this view began to change in 1897 when Rehn, a German physician, successfully performed the first repair of a penetrating human heart injury. A series of successful salvage cases soon followed and were reported. In the early twentieth century, the reported success rate was between 40 and 50%. Over time, increased awareness of the clinical symptoms of penetrating cardiac injury, especially of cardiac compression, the invention and application of diagnostic equipment, and the availability of cardiac suturing techniques and emergency dissection techniques led to an increasing success rate. 1999 Thourani et al. summarized 192 patients over a 22-year period with an overall success rate of 75%, and David G et al. in 1999 reported a survival rate of 92% in a group of 128 patients. Second, the classification of penetrating cardiac injuries is mainly divided into stab wounds and firearm wounds, and the proportion of both varies greatly from country to country and from period to period. The vast majority of domestic cases are stab wounds. Campbell, South Africa, reported 1198 cases of penetrating cardiac injuries between 1990 and 1992, 84% of which were stab wounds and 16% were firearm wounds. In the United States, the proportion of firearm injuries varies among reports, but the overall trend has increased over the past three decades, reaching 65%-70% in recent years. Firearm injuries have a higher mortality rate compared to stab wounds, with a difference of about 2-4 times, mainly due to the fact that firearm injuries are more likely to lead to multiple heart cavity injuries and combined injuries. Clinical manifestations From complete hemodynamic stability to cardiac arrest, different pathophysiological changes can occur after cardiac penetrating injuries. This depends on the mechanism of injury, the time from injury to treatment, and the location and extent of injury. Depending on the size and location of the heart and pericardium, blood may accumulate in the pericardial cavity, flow into the pleural cavity, or flow outside the body, causing cardiac tamponade or blood loss. If both the heart and pericardial wounds are large enough, blood will flow into the left side of the chest cavity or out of the body, causing death when blood loss exceeds 40-50% of the circulating blood volume. The main manifestation of blood loss is about 10-14% of patients. 51-78% of patients present with cardiac tamponade. moreno et al. performed a retrospective analysis of 100 patients and found a survival rate of 73% in patients presenting with cardiac tamponade, compared to 11% in patients not presenting with cardiac tamponade. Similar results were reported by Carlos et al. They concluded that the presence or absence of cardiac compressions is one of the key factors in patient survival. However, Juan et al. performed a multifactorial regression analysis on 105 patients and the results suggested that the presence or absence of cardiac compressions was not associated with mortality. Most authors believe that cardiac compression is two-sided in that it prevents blood from flowing out of the pericardium, avoiding hemorrhagic shock and allowing the patient the opportunity to receive treatment. However, it also compresses the heart chambers, affecting blood return and reducing cardiac output or even cardiac arrest. There are no data to define how long the protective effect of cardiac compression on blood loss lasts and when it turns harmful. About 1/3 of patients exhibit a stable circulatory status after injury, mainly due to a heart laceration blocked by a blood clot after experiencing a relatively mild blood loss or cardiac compression. However, this stable state is only temporary, and some of such cases deteriorate or even die after being missed, with the underlying cause being mostly delayed cardiac compressions. The clinical manifestations of cardiac tamponade are highly variable, with the traditional Beck’s triad appearing in only 10-40% of patients, the most frequent of which is an increase in central venous pressure. When combined with hypovolemia caused by blood loss and manifested as a low-pressure type of cardiac tamponade, the symptoms are even more atypical, and central venous pressure may still be normal after severe hemodynamic compromise, while the odd pulse is even less frequent, making diagnosis difficult. Emergency cardiac ultrasound was first applied to cardiac trauma by Choo in 1984 [20]. Jimenez conducted a prospective study of a group of 73 patients with penetrating cardiac injuries and concluded that the accuracy of cardiac ultrasound was 96%, the specificity was 97%, and the sensitivity was 90%. Plummer et al. reduced the admission-to-operation time from 42.4 to 15.5 minutes and increased the survival rate from 57% to 100% since the application of emergency cardiac ultrasound. Since the early 1990s, many surgeons, unwilling to be limited by the availability of ultrasound operators (usually off duty during peak trauma hours), have begun to perform their own cardiac ultrasound, reducing the time to 0.8 minutes with an accuracy rate of 98%. 1999 Thourani categorized emergency cardiac ultrasound as one of the three major advances in the management of penetrating cardiac injuries (prehospital rapid transport system, emergency Cardiac ultrasound, early surgical intervention) and was highly regarded. Pericardiocentesis is associated with an 80% false-negative rate and frequent false-positive rates in the presence of intrapericardial clot formation, and although some authors have suggested that pericardiocentesis has a concurrent therapeutic role, the complication rate is quite high. With the widespread use of cardiac ultrasound, most surgeons in recent years have discontinued pericardiocentesis as a diagnostic and therapeutic tool for penetrating cardiac injuries. When the diagnosis cannot be established, some authors use subxiphoid pericardial opening exploration, but in addition to having about 20% false negatives, this approach is considered by more authors to waste valuable resuscitation time and to allow the patient to continue to lose blood from the drainage tube. When the patient is still stable and needs to be explored, it is better to use a small anterior thoracic incision, which can provide sufficient exposure for cardiac repair if necessary. Morales performed thoracoscopically assisted diagnostic pericardial openings with 100% sensitivity, 96% specificity, and 97% accuracy in 108 cases of suspected penetrating cardiac injuries that could not be clearly identified as stable. Despite the extremely low success rate of emergency room dissection (10%-15%), many surgeons still see great value in this complex and extremely challenging approach. If the patient is still hemodynamically stable, an OR dissection can achieve a 3-fold higher success rate than an ER dissection if possible after a clear diagnosis is made. However, patients in a near-death state, such as cardiac arrest or systolic blood pressure below 60 mmHg, should undergo emergency room dissection, and these indications are widely accepted. Emergency room dissection allows for intrathoracic cardiac compressions (which can save about 10% of patients in cardiac arrest), repair of the injury if possible, immediate control of bleeding, release of cardiac compressions, prevention of air embolism, and also temporary blockage of the descending aorta to ensure perfusion of the myocardium. Emergency room dissection of the chest is mostly performed using a lateral thoracotomy, which allows rapid access to the chest. Non-invasive sutures (such as prolene sutures) are used to close the cardiac laceration. For larger wounds or multi-chamber injuries that are difficult to handle in the emergency room, some adjunctive methods can be used to temporarily stop bleeding, such as balloon catheters or staple closures, and then sent to the operating room for further treatment after hemodynamic stabilization. Feliciano et al. used skin staple closures as a temporary means of hemostasis for dissection in the emergency room and later replaced them with conventional sutures after being sent to the operating room. In contrast, some authors have left the staples in the body without further removal, believing that there is no effect on the wound, but no long-term follow-up data are available to demonstrate this. Mayrose et al. confirmed after animal studies that the use of a stapled closure for repairing cardiac lacerations requires significantly less time than the traditional suspect suture technique with equal mechanical strength and is particularly suitable for emergency cardiac repair. However, Juan [10] et al. took the opposite view, arguing that stapled closures are not effective in stopping bleeding and may make the wound laceration larger. In patients with suture difficulties, Roger et al. used 0.15-0.3 mg/kg adenosine (trade name: Adenocard) intravenously to induce a cardiac arrest of about 20 seconds, allowing the surgeon to precisely perform the most critical sutures with the heart at rest. Eastman et al. coated pericardial slices with a household acrylic adhesive and taped the wound to stop bleeding and performed six cases successfully, but no other relevant reports on this therapy have been published.