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Case Study
Cardiac herniation after left intrapericardial pneumonectomy
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315589199 aan.sagepub.com
Faouzi Alimi1, Mohamed Marzouk1, Imen Mgarrech1, Haythem Chemchik2 and Faouzi Limayem1
Abstract Postoperative cardiac herniation is a rare fatal complication that requires urgent surgical reduction and closure of the pericardial defect. Cardiac herniation occurred 8 h after a left intrapericardial pneumonectomy. Although the patient was completely asymptomatic, acute hemodynamic failure with electrocardiographic changes occurred. Chest radiographs were not helpful in showing cardiac herniation. The patient was immediately brought back to the operating room. Cardiac herniation was found to be caused by a pericardial defect, and the heart was strangulated at the atrioventricular groove level. The heart was repositioned, but hemodynamic instability inherent to ischemic strangulation lesions persisted despite extracorporeal membrane oxygenation.
Keywords Hernia, pericardiectomy, pneumonectomy, postoperative complications, shock, cardiogenic
Introduction Cardiac herniation after lung resection is a rare lifethreatening complication related to an ignored or inadequately closed pericardial sac defect. It usually occurs within the first 24 h postoperatively, but it can occur later after surgery.1,2 It may be observed after lung cancer surgery, an intrapericardial pneumonectomy or lesser resection involving opening or resection of the pericardium to treat mediastinal neoplasia.3–5 We report a case of cardiac herniation after a left intrapericardial pneumonectomy, with a fatal outcome that we deem an avoidable fatal complication, particularly in the hands of thoracic surgeons.
Case report A 44-year-old man was referred to our department for lung cancer surgery. His lung neoplasia, confirmed by biopsy as adenocarcinoma, was assessed as resectable without neoadjuvant chemotherapy despite local involvement of the left pulmonary artery at its origin. A left intrapericardial pneumonectomy was performed and was well tolerated without any hemodynamic or electrocardiographs changes. In the early postoperative hours, the patient was asymptomatic, but at the 8th
postoperative hour, he developed severe cardiogenic shock associated with electrocardiographic changes, without apparent hemorrhage. He was immediately brought back to the operating room and cardiac herniation due to a pericardial defect was found. The heart was strangulated at the level of the atrioventricular groove (Figure 1). The heart was repositioned, but hemodynamic instability inherent to ischemic strangulation lesions persisted despite extracorporeal membrane oxygenation. In spite of optimal lung and circulation support, we were unable to restore hemodynamic stability or lung gas exchange. With the onset of multiple organ failure syndrome, a fatal outcome was unavoidable, and death occurred on the 5th postoperative day.
1 Department of Cardiothoracic Surgery, Sahloul University Hospital, Sousse, Tunisia 2 Department of Anesthesiology and Critical Care, Sahloul University Hospital, Sousse, Tunisia
Corresponding author: Faouzi Alimi, MD, Department of Cardiothoracic Surgery, Sahloul University Hospital, Sousse 4054, Tunisia. Email: [email protected]
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Figure 1. Operative view through an iterative left thoracotomy. The heart was rotated through the pericardial defect, with the left ventricular apex (arrow) shifted posteriorly and up to the left. The result was that both left and right ventricles were strangulated at the atrioventricular groove level, and cardiac inflow ceased with rapid catastrophic hemodynamic failure and ischemic lesions.
Discussion Cardiac herniation is a rare condition with a potentially fatal outcome if not treated promptly. It usually manifests in the first 24 h postoperatively, but some herniations have been observed as late as 28 h to 6 months.1,2 The incidence is similar on both sides, but the mechanism of hemodynamic failure differs. On the right side, the problem is mainly torsion of the superior and inferior venae cavae. With a pericardial defect on the left side, the left ventricular apex can rotate through the foramen and become strangulated at a different level. The heart may rotate through the pericardial defect with the left ventricular apex shifting anteriorly up and to the left, as in this case. The result is rapid catastrophic hemodynamic failure. Such strangulation affects mechanical filling as well as emptying of the cardiac chambers. This may be more severe when strangulation takes place at the atrioventricular groove level. Furthermore, impairment of coronary blood flow sustains the hemodynamic instability, which in our case was the most important pejorative element, and specific treatment might have been helpful to avoid a fatal outcome if recognized in time.6 Cardiac herniation must be recognized early and treated rapidly. The mortality rate of this complication remains high: in cases recognized early it is 50%, and in cases undetected or recognized late it is 100%. Cardiovascular collapse is the main symptom observed, the severity may vary but it will lead to death if not treated. Any hemodynamic or electrocardiographic
changes in the early or even the late postoperative period in patients who have undergone pneumonectomy or a lesser resection associated with a pericardial sac defect, should alert us to the possibility of cardiac herniation.3–5 A chest radiograph may be helpful after a right lung resection, showing right displacement of the heart through the defect, but on the left side, it is not usually identified on an anteroposterior chest radiograph, although it can sometimes be appreciated on a lateral radiograph. When a diagnosis of cardiac herniation following a left pneumonectomy is suspected, the patient must be turned onto the right side, in the hope of spontaneous reduction, even partially. Surgical reduction of the heart and closure of the pericardial defect must be performed without delay. Although most cases have been reported in situations where the pericardial defect was not closed, including ours, this diagnosis cannot be eliminated in patients with a pericardial prosthesis because torsion can occur with apparently adequate closure and also when the pericardium is sutured to the myocardium with multiple stitches to prevent herniation.2 However, in many of the reports of cardiac herniation, there was no pericardial reconstruction defect or dehiscence of sutures. It is reasonable to conclude that cardiac herniation following pneumonectomy or partial lung resection with a pericardial sac defect can be described as an avoidable complication.3–5 Cardiac herniation after lung resection remains a serious life-threatening but preventable complication, and closure of the pericardial defect should be undertaken systematically by an experienced thoracic surgeon. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Zandberg FT, Verbeke SJ, Snijder RJ, Dalinghaus WH, Roeffel SM and Van Swieten HA. Sudden cardiac herniation 6 months after right pneumonectomy. Ann Thorac Surg 2004; 78: 1095–1097. 2. Baaijens PF, Hasenbos MA, Lacquet LK and Dekhuijzen PN. Cardiac herniation after pneumonectomy. Acta Anaesthesiol Scand 1992; 36: 842–845. 3. Karalapillai D, Larobina M, Stevenson K and Doolan L. A change of heart: acute cardiac dextroversion with cardiogenic shock after partial lung resection. Crit Care Resusc 2008; 10: 140–143.
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4. Sonoda S, Kumagawa Y and Inada E. A case of cardiac herniation after extrapleural pneumonectomy for malignant thymoma. J Anesth 2010; 24: 926–929. 5. Ponten JE, Elenbaas TW, Ter Woorst JF, Korsten EH, Van Den Borne BE and Van Straten AH. Cardiac herniation after operative management of lung cancer: a rare and
dangerous complication. Gen Thorac Cardiovasc Surg 2012; 60: 668–672. 6. Terauchi Y, Kitaoka H, Tanioka K, et al. Inferior acute myocardial infarction due to acute cardiac herniation after right pneumonectomy. Cardiovasc Interv Ther 2012; 27: 110–113.
Downloaded from aan.sagepub.com by guest on November 14, 2015
(AAN)
[1–3] [PREPRINTER stage]
Case Study
Cardiac herniation after left intrapericardial pneumonectomy
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315589199 aan.sagepub.com
Faouzi Alimi1, Mohamed Marzouk1, Imen Mgarrech1, Haythem Chemchik2 and Faouzi Limayem1
Abstract Postoperative cardiac herniation is a rare fatal complication that requires urgent surgical reduction and closure of the pericardial defect. Cardiac herniation occurred 8 h after a left intrapericardial pneumonectomy. Although the patient was completely asymptomatic, acute hemodynamic failure with electrocardiographic changes occurred. Chest radiographs were not helpful in showing cardiac herniation. The patient was immediately brought back to the operating room. Cardiac herniation was found to be caused by a pericardial defect, and the heart was strangulated at the atrioventricular groove level. The heart was repositioned, but hemodynamic instability inherent to ischemic strangulation lesions persisted despite extracorporeal membrane oxygenation.
Keywords Hernia, pericardiectomy, pneumonectomy, postoperative complications, shock, cardiogenic
Introduction Cardiac herniation after lung resection is a rare lifethreatening complication related to an ignored or inadequately closed pericardial sac defect. It usually occurs within the first 24 h postoperatively, but it can occur later after surgery.1,2 It may be observed after lung cancer surgery, an intrapericardial pneumonectomy or lesser resection involving opening or resection of the pericardium to treat mediastinal neoplasia.3–5 We report a case of cardiac herniation after a left intrapericardial pneumonectomy, with a fatal outcome that we deem an avoidable fatal complication, particularly in the hands of thoracic surgeons.
Case report A 44-year-old man was referred to our department for lung cancer surgery. His lung neoplasia, confirmed by biopsy as adenocarcinoma, was assessed as resectable without neoadjuvant chemotherapy despite local involvement of the left pulmonary artery at its origin. A left intrapericardial pneumonectomy was performed and was well tolerated without any hemodynamic or electrocardiographs changes. In the early postoperative hours, the patient was asymptomatic, but at the 8th
postoperative hour, he developed severe cardiogenic shock associated with electrocardiographic changes, without apparent hemorrhage. He was immediately brought back to the operating room and cardiac herniation due to a pericardial defect was found. The heart was strangulated at the level of the atrioventricular groove (Figure 1). The heart was repositioned, but hemodynamic instability inherent to ischemic strangulation lesions persisted despite extracorporeal membrane oxygenation. In spite of optimal lung and circulation support, we were unable to restore hemodynamic stability or lung gas exchange. With the onset of multiple organ failure syndrome, a fatal outcome was unavoidable, and death occurred on the 5th postoperative day.
1 Department of Cardiothoracic Surgery, Sahloul University Hospital, Sousse, Tunisia 2 Department of Anesthesiology and Critical Care, Sahloul University Hospital, Sousse, Tunisia
Corresponding author: Faouzi Alimi, MD, Department of Cardiothoracic Surgery, Sahloul University Hospital, Sousse 4054, Tunisia. Email: [email protected]
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Asian Cardiovascular & Thoracic Annals 0(0)
Figure 1. Operative view through an iterative left thoracotomy. The heart was rotated through the pericardial defect, with the left ventricular apex (arrow) shifted posteriorly and up to the left. The result was that both left and right ventricles were strangulated at the atrioventricular groove level, and cardiac inflow ceased with rapid catastrophic hemodynamic failure and ischemic lesions.
Discussion Cardiac herniation is a rare condition with a potentially fatal outcome if not treated promptly. It usually manifests in the first 24 h postoperatively, but some herniations have been observed as late as 28 h to 6 months.1,2 The incidence is similar on both sides, but the mechanism of hemodynamic failure differs. On the right side, the problem is mainly torsion of the superior and inferior venae cavae. With a pericardial defect on the left side, the left ventricular apex can rotate through the foramen and become strangulated at a different level. The heart may rotate through the pericardial defect with the left ventricular apex shifting anteriorly up and to the left, as in this case. The result is rapid catastrophic hemodynamic failure. Such strangulation affects mechanical filling as well as emptying of the cardiac chambers. This may be more severe when strangulation takes place at the atrioventricular groove level. Furthermore, impairment of coronary blood flow sustains the hemodynamic instability, which in our case was the most important pejorative element, and specific treatment might have been helpful to avoid a fatal outcome if recognized in time.6 Cardiac herniation must be recognized early and treated rapidly. The mortality rate of this complication remains high: in cases recognized early it is 50%, and in cases undetected or recognized late it is 100%. Cardiovascular collapse is the main symptom observed, the severity may vary but it will lead to death if not treated. Any hemodynamic or electrocardiographic
changes in the early or even the late postoperative period in patients who have undergone pneumonectomy or a lesser resection associated with a pericardial sac defect, should alert us to the possibility of cardiac herniation.3–5 A chest radiograph may be helpful after a right lung resection, showing right displacement of the heart through the defect, but on the left side, it is not usually identified on an anteroposterior chest radiograph, although it can sometimes be appreciated on a lateral radiograph. When a diagnosis of cardiac herniation following a left pneumonectomy is suspected, the patient must be turned onto the right side, in the hope of spontaneous reduction, even partially. Surgical reduction of the heart and closure of the pericardial defect must be performed without delay. Although most cases have been reported in situations where the pericardial defect was not closed, including ours, this diagnosis cannot be eliminated in patients with a pericardial prosthesis because torsion can occur with apparently adequate closure and also when the pericardium is sutured to the myocardium with multiple stitches to prevent herniation.2 However, in many of the reports of cardiac herniation, there was no pericardial reconstruction defect or dehiscence of sutures. It is reasonable to conclude that cardiac herniation following pneumonectomy or partial lung resection with a pericardial sac defect can be described as an avoidable complication.3–5 Cardiac herniation after lung resection remains a serious life-threatening but preventable complication, and closure of the pericardial defect should be undertaken systematically by an experienced thoracic surgeon. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Zandberg FT, Verbeke SJ, Snijder RJ, Dalinghaus WH, Roeffel SM and Van Swieten HA. Sudden cardiac herniation 6 months after right pneumonectomy. Ann Thorac Surg 2004; 78: 1095–1097. 2. Baaijens PF, Hasenbos MA, Lacquet LK and Dekhuijzen PN. Cardiac herniation after pneumonectomy. Acta Anaesthesiol Scand 1992; 36: 842–845. 3. Karalapillai D, Larobina M, Stevenson K and Doolan L. A change of heart: acute cardiac dextroversion with cardiogenic shock after partial lung resection. Crit Care Resusc 2008; 10: 140–143.
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4. Sonoda S, Kumagawa Y and Inada E. A case of cardiac herniation after extrapleural pneumonectomy for malignant thymoma. J Anesth 2010; 24: 926–929. 5. Ponten JE, Elenbaas TW, Ter Woorst JF, Korsten EH, Van Den Borne BE and Van Straten AH. Cardiac herniation after operative management of lung cancer: a rare and
dangerous complication. Gen Thorac Cardiovasc Surg 2012; 60: 668–672. 6. Terauchi Y, Kitaoka H, Tanioka K, et al. Inferior acute myocardial infarction due to acute cardiac herniation after right pneumonectomy. Cardiovasc Interv Ther 2012; 27: 110–113.
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![[Cardiac herniation and sub-herniation. Complication of intrapericardial pneumonectomy].](/assets/img/hold.png)
