*From the Departments of Thoracic Surgery (Drs. Montero, Gimferrer, Serra, Catalán, and Canalís) and Anesthesiology (Dr. Fita), Hospital Clínic, Universitat de Barcelona, Spain.
Correspondence to: Carlos A. Montero, MD, Department of Thoracic Surgery, Hospital Clinic, Universitat de Barcelona, 170 Villarroel St, 08036 Barcelona, Spain; e-mail: email@example.com
-year-old male patient with noncomplicated alcoholic liver disease
presented with a right upper parahilar pulmonary mass after minor blunt
chest trauma. After an appropriate workup, non-small cell carcinoma of
the lung was diagnosed. A right intrapericardial pneumonectomy was
performed. A silastic chest drain with no negative pressure was left
connected to a compensatory postpneumonectomy system. The patient was
extubated 30 min after the operation. A few minutes later while in the
recovery room, the patient developed atrial fibrillation with fast
heart rate of 150 beats/min. Digoxin and amiodarone were started.
Shortly thereafter, ventricular fibrillation required a 300-J/s direct
current shock. The patient was intubated again, and cardiopulmonary
resuscitation was performed. Complete atrioventricular block developed,
and a percutaneous transjugular right ventricular pacing lead was
inserted. A chest radiograph demonstrated mediastinal shift toward
the pneumonectomy side (Fig 1)
The patient was positioned on the left side, and his condition
improved. The decision was immediately made to reopen the chest. Left
atrial herniation was apparent through the pericardial gap. It was easy
to replace the heart to its normal position because of the wide
opening, which was closed with a running polypropylene suture.
Twenty-four hours after reopening, the patient required a second
exploration due to cardiogenic shock. A chest radiograph showed a right
white hemithorax. A massive clot was found, and no specific bleeding
site was confirmed. The patient was extubated on the third
postoperative day and discharged from the ICU.
Cardiac herniation is a rare and life-threatening event with a
mortality rate from 50 to 100%, as reported in the literature. It
occurs in association with congenital pericardial defects and traumatic
disruption of the pericardial sac.1It is also seen as a
complication of pulmonary surgery, especially intrapericardic
pneumonectomy without closure of pericardial defect,2–3 or
lobar resection with pericardial opening.4–5 It appears to
be related to negative intrapleural pressure, positive-pressure
breathing, or changes in the position of the patient.
The sudden onset generally occurs within 24 h after surgery, and
the symptoms are related to the side of herniation. On the left side,
symptoms will result from strangulation of the ventricle and they may
include dysrhythmia, myocardial ischemia, hypotension, and shock. In
the case of herniation on the right side, a superior vena cava syndrome
caused by torsion of this structure5 may ensue, resulting
in a reduction of venous return, although outflow tract obstruction may
We can conclude that any patient who has had a pneumonectomy or a
partial lung resection in which the pericardial gap has not been closed
can present with this fatal entity. The patient must be closely
followed to detect any hemodynamic disturbance or cardiac dysrhythmia,
keeping in mind this possibility.
Differential diagnosis includes massive intrathoracic hemorrhage,
atelectasis of the remaining lung tissue, and pulmonary
embolism.6 The importance of early diagnosis and immediate
surgical treatment with relocation of the heart to its anatomic
position and repair of the pericardial defect, either primarily or by
using autologous or prosthetic material, is a key issue in the outcome
of the patient.
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