Wounds of the Left Ventricle

Left: Bullet wound, death after two days.
Right: Stab wound, death after two hours.

Top: Ludwig Rehn

As common as heart surgery is today, it’s hard to imagine that it wasn’t really developed until the 1950s and 60s. Even the repair of cardiac wounds was only attempted starting at the turn of the century. The heart is incredibly powerful, yet so easy to damage, leading to the belief that the pericardium would always be a place where “surgeons will never breach”. Wounds to the heart were considered invariably fatal.

The first “true” heart surgery (performed on the heart muscle and not just the pericardium) was performed on September 9, 1896 by Ludwig Rehn, on a case similar to the stab wound illustrated on the right side of the image. From the case report:

W. J., a 22-year-old gardener, was discharged from the
military on August 31, 1896, because of an irregular
heartbeat. On the evening of September 7, he sustained
a knife wound during a walk, and fell to the ground
unconscious. A passerby found him several hours later.
At 3:30 A.M., he arrived at the State Hospital.

The next day, the 1.5 cm-long incision was causing rapidly increasing hemothorax (blood in the thorax, fatal if not corrected) and auscultation determined that the wound was in the heart proper, not an intercostal or mammary artery. Dr. Rehn decided to attempt to close the wound, against the advice of a lower-ranking cardiologist. Working in time with the weakened heartbeat, Dr. Rehn placed three sutures along the wound, and all bleeding from the heart ceased. A pleural drain was placed (to clear out the blood and fluid accumulated in the chest), and the operation concluded.

Though there were initial concerns that the patient may develop pericarditis or other infectious complications, none arose, and six months later the patient was back to light work and in good spirits. Rehn remarked in his publication of the case:

Gentlemen! The feasibility of cardiorrhaphy no longer remains
in doubt. I need not fear any objections as to its propriety; the
operation not only was lifesaving, but prevented the subsequent
development of constrictive pericarditis. I trust that this
case will not remain a curiosity, but rather, that the field of
cardiac surgery will be further investigated. Let me speak once
more my conviction that by means of the cardiorrhaphy, many
lives can be saved that were previously counted as lost!

Though it was many years before survival was feasible in a majority of heart surgery cases, this paved the way forward for exploration of a previously-“sacred” cavity of the body.

Diseases of the Heart and Aorta. Arthur Douglass Hirschfelder, 1912.

Ludwig Rehn: The First Successful Cardiorrhaphy. James W. Blatchford III. Annals of Thoracic Surgery 1985;39:492-495

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