Cardiac Herniation Through a Pericardial Defect After Minimally Invasive Mitral Valve Surgery Negmeldeen F. Mamoun, MD, PhD,* Colleen G. Koch, MD, MS,* and A. Marc Gillinov, MD† Minimally invasive mitral valve surgery has been increasingly performed because of its presumed advantages over traditional surgery performed through median sternotomy. Cardiac herniation is an extremely rare complication initially reported by Bettman and Tannenbaum in 1948. It is usually reported after blunt chest trauma or pneumonectomy, but can potentially occur after any minimally invasive surgery involving a pericardial incision. In this case report, we present 2 cases of cardiac herniation occurring after minimally invasive mitral valve surgery; the 2 cases had different surgical exposures and clinical presentations. Early diagnosis is crucial for a timely lifesaving definitive management. (A&A Case Reports 2013;1:79–81)
M
inimally invasive mitral valve (MV) surgery has presumed advantages over that performed through median sternotomy. Smaller incisions are associated with reduced pain, reduced blood loss and transfusions, faster recovery, shorter hospital length of stay, and increased patient satisfaction. However, this approach is also associated with longer cardiopulmonary bypass (CPB) and cross-clamp times and complications unique to femoral cannulation and femoro-femoral bypass.1 Cardiac herniation is an extremely rare complication initially reported by Bettman and Tannenbaum in 1948.2 It usually follows blunt chest trauma3 or pneumonectomy,4 but can potentially occur after any minimally invasive surgery involving a pericardial incision. In this case report, we present 2 cases of cardiac herniation occurring after minimally invasive MV surgery; the 2 cases had different surgical exposures and clinical presentations. Early diagnosis is crucial for a timely lifesaving definitive management. Waiver of patient consent was obtained from IRB because both patients could not be reached.
placed. Successful repair was confirmed by easily acquired standard transesophageal echocardiography (TEE) views (Fig. 1A; Video 1, see Supplemental Digital Content 1, http://links.lww.com/AACR/A2).
CASE DESCRIPTION 1
A 44-year-old man with asymptomatic severe degenerative MV disease and severe mitral regurgitation underwent mitral valvuloplasty through a 4-cm right minithoracotomy. After induction of general anesthesia, a double-lumen tube was placed to facilitate left-sided 1-lung ventilation. The right internal jugular vein was percutaneously cannulated by both 7.5-Fr triple-lumen, and 16-gauge single-lumen catheters. Femoro-femoral CPB was started after femoral arterial and venous cannulation. The pericardium was opened, and a coronary sinus catheter was placed by the surgeon. MV prolapse was repaired, and a Duran ring was From the Departments of *Cardiothoracic Anesthesiology and †Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Accepted for publication April 25, 2013. Funding: Not applicable. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (cases.anesthesia-analgesia.org). Address correspondence to Negmeldeen F. Mamoun, MD, PhD, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, 9500 Euclid Ave./J4-331, Cleveland, OH 44195. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e31829c685d
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Figure 1. A, Midesophageal 4-chamber transesophageal echocardiographic (TEE) view obtained at 0° after mitral valve repair and before cardiac herniation. B, Nonstandard TEE view obtained also at 0° after cardiac herniation. C, Midesophageal 4-chamber TEE view after correction of cardiac herniation. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle. cases-anesthesia-analgesia.org
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Cardiac Herniation After Mitral Valve Surgery
Video 1. Transesophageal echocardiographic (TEE) view: midesophageal 4-chamber obtained at 0° after mitral valve repair and before cardiac herniation. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
Video 3. Transesophageal echocardiographic (TEE) view: midesophageal 4-chamber obtained at 0° after correction of cardiac herniation. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
While being moved from the operating room table to the intensive care unit (ICU) bed at the end of surgery, the patient became hypotensive but responded to fluids and intermittent boluses of vasopressors. A TEE probe was replaced for further evaluation of the etiology of hypotension, but we were unable to adequately image the heart with standard midesophageal views (Fig. 1B; Video 2, see Supplemental Digital Content 2, http://links.lww.com/AACR/A3), and completely unable to visualize the heart with transgastric views. The descending aorta was visualized, and no dissection was noted. The chest was reexplored because of continued need for vasopressor support and inability to image the heart adequately. On surgical exposure, the right lung was found to be incompletely inflated and the heart had herniated through the pericardial defect and was twisted over its primary axis into the right hemithorax. After simple manual repositioning of the heart, stable hemodynamics and standard TEE views were restored (Fig. 1C; Video 3, see Supplemental Digital Content 3, http://links.lww.com/AACR/A4); findings were unchanged from the TEE examination done immediately after MV repair. The pericardium was closed with 3 interrupted sutures, and the right lung was reinflated under direct visualization. The patient was transported to the ICU
in stable condition; he was later transferred to the floor on the first postoperative day (POD) and was discharged on the fourth POD after an uneventful hospital course.
CASE DESCRIPTION 2
A 49-year-old man with asymptomatic severe degenerative MV disease and severe mitral regurgitation underwent robotically assisted minimally invasive mitral valvuloplasty through multiple small ports in the right chest. Anesthetic and surgical management was similar to that of the first case with the exception that a coronary sinus catheter was not placed, and only antegrade cardioplegia was delivered. MV repair was successful as confirmed by TEE examination done after CPB; the patient was transported to the ICU after an uneventful intraoperative course. Routine chest radiograph performed on ICU admission revealed herniation of the heart into the right hemithorax (Fig. 2A). The patient was completely asymptomatic, chest radiograph was repeated after leaning the patient toward his left side, but it was unchanged. The patient was transferred back to the operating room, the heart was manually repositioned to its anatomical position, and the pericardial defect was closed with a synthetic patch. A chest radiograph on arrival to the ICU confirmed that cardiac herniation was corrected (Fig. 2B). The patient was transferred to the floor on the first POD and was discharged on the sixth POD after an uneventful hospital course.
DISCUSSION
Video 2. Nonstandard transesophageal echocardiographic (TEE) view obtained at 0° after cardiac herniation. LA = left atrium; LV = left ventricle.
80 cases-anesthesia-analgesia.org
Cardiac herniation is a very rare and dangerous complication with a mortality rate approaching 50%.5 The few recent reports of cardiac herniation after minimally invasive cardiac surgery6–8 all had different clinical presentations. Symptoms depend on the side of cardiac herniation; only right-sided herniation is possible with minimally invasive MV surgery as the pericardium is incised on the right side. Right-sided herniation has a wide spectrum of presentations from asymptomatic to severe hypotension, tachycardia, and superior vena cava syndrome; the presentation usually depends on the degree of impediment of superior and inferior vena caval inflow.9 One of our patients was completely
A & A case reports
Figure 2. A, Chest radiograph with cardiac herniation in the right hemithorax. B, Chest radiograph after cardiac repositioning to its anatomical position.
asymptomatic, while the other exhibited mild hemodynamic instability that was controlled with fluids and vasopressors. Nonspecific symptoms make the diagnosis of cardiac herniation more difficult. However, timely diagnosis is critical because if the patient’s condition deteriorates and cardiopulmonary resuscitation is initiated, chest compressions are useless because the heart is not in its anatomical position. Factors triggering cardiac herniation include a marked increase in intrathoracic pressure, which is usually associated with excessive ventilation of the contralateral lung (e.g., strong positive pressure ventilation when coming off CPB), coughing on extubation, excessive suction from ipsilateral chest tubes, or positioning the side of surgery more dependently.10 In our first case, turning the patient to his right side to place the roller underneath him or the acceleration–deceleration associated with patient movement to the ICU bed likely facilitated herniation of the heart through the open pericardium into the right chest cavity. However, in our second case, the event triggering the herniation is uncertain given that it was asymptomatic and unrecognized until ICU admission. It is important to avoid triggering factors within the first 24 hours after surgery; the vast majority of cardiac herniations have been reported during that time frame. Adhesions tend to form between the pericardium and the heart very quickly, decreasing the incidence of late cardiac herniation.11 Diagnosis of cardiac herniation may be confirmed by chest radiograph revealing a “snow cone” shape of the right border of the heart if herniation is partial or impending,12 or as in our second case, it may reveal a complete herniation with shifting of the cardiac shadow from the left to the right hemithorax. Chest radiograph can also reveal reversal of a pulmonary artery catheter loop and rotation in a clockwise fashion.13 Computed tomography scan,7 magnetic resonance imaging,3 transthoracic echocardiography,11 TEE, and video-assisted thoracoscopy8 have been used in different capacities to diagnose cardiac herniation as well. While hypotension after cardiac surgery is not uncommon, and in our first case initially responded to fluids and vasopressors, it was the inability to image the heart adequately from standard TEE views that alerted our team to the possibility of cardiac herniation, particularly recognizing that standard views were easily acquired a few minutes earlier. Definitive management of cardiac herniation includes surgical exploration to reposition the heart back to its anatomical position and closing the pericardial defect primarily or using synthetic mesh or bovine pericardium. Additional treatment measures include positioning the nonsurgical side more dependently and avoiding hyperinflation of
December 15, 2013 • Volume 1 • Number 6
the contralateral lung.9 It is prudent to routinely close any pericardial defect after minimally invasive cardiac surgery irrespective of how small it is. However, cardiac herniation should always be considered even if the pericardium was repaired; herniation has been reported to happen when the pericardial repair broke in the early postoperative period.14 In this case report, we present 2 patients in whom rightsided cardiac herniation followed minimally invasive mitral valvuloplasty. The 2 examples of herniation had different clinical presentations, which made the diagnosis more difficult. Cardiac herniation is an extremely rare and potentially fatal complication requiring early detection and timely definitive management. E REFERENCES 1. Modi P, Hassan A, Chitwood WR Jr. Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2008;34:943–52 2. Bettman RB, Tannenbaum WJ. Herniation of the heart: through a pericardial incision. Ann Surg 1948;128:1012–4 3. Sohn JH, Song JW, Seo JB, Do KH, Lee JS, Kim DK, Song KS, Lim TH. Case report: pericardial rupture and cardiac herniation after blunt trauma: a case diagnosed using cardiac MRI. Br J Radiol 2005;78:447–9 4. Mehanna MJ, Israel GM, Katigbak M, Rubinowitz AN. Cardiac herniation after right pneumonectomy: case report and review of the literature. J Thorac Imaging 2007;22:280–2 5. Self RJ, Vaughan RS. Acute cardiac herniation after radical pleuropneumonectomy. Anaesthesia 1999;54:564–6 6. Wasir H, Malhotra R, Vats M, Sharma KK, Mehta Y, Trehan N. Cardiac herniation following atrial septal defect closure using port access surgery. Indian Heart J 2006;58:260–2 7. Speggiorin S, Padalino MA, Vida VL, Bonato R, Stellin G. Cardiac herniation after minimally invasive cardiac surgery: an unusual potentially lethal complication. Circulation 2009;120:2509–10 8. Yamaguchi S, Ishikawa N, Watanabe G. Cardiac herniation during robot-assisted cardiac operation. J Thorac Cardiovasc Surg 2012;143:e10–1 9. Cassorla L, Katz JA. Management of cardiac herniation after intrapericardial pneumonectomy. Anesthesiology 1984;60:362–4 10. Shimizu J, Ishida Y, Hirano Y, Tatsuzawa Y, Kawaura Y, Nozawa A, Yamada K, Oda M. Cardiac herniation following intrapericardial pneumonectomy with partial pericardiectomy for advanced lung cancer. Ann Thorac Cardiovasc Surg 2003;9:68–72 11. Nanda S, Pamula J, Bhatt SP, Turki MA, Myers E, Dale T. Cardiac herniation and volvulus with acquired dextrocardia: echocardiographic diagnosis. Echocardiography 2007;24:870–4 12. Gurney JW, Arnold S, Goodman LR. Impending cardiac herniation: the snow cone sign. Radiology 1986;161:653–5 13. Brogdon BG, Georgy BA. An unusual twist. Br J Radiol 1998;71:691–2 14. Veronesi G, Spaggiari L, Solli PG, Pastorino U. Cardiac dislocation after extended pneumonectomy with pericardioplasty. Eur J Cardiothorac Surg 2001;19:89–91
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M
inimally invasive mitral valve (MV) surgery has presumed advantages over that performed through median sternotomy. Smaller incisions are associated with reduced pain, reduced blood loss and transfusions, faster recovery, shorter hospital length of stay, and increased patient satisfaction. However, this approach is also associated with longer cardiopulmonary bypass (CPB) and cross-clamp times and complications unique to femoral cannulation and femoro-femoral bypass.1 Cardiac herniation is an extremely rare complication initially reported by Bettman and Tannenbaum in 1948.2 It usually follows blunt chest trauma3 or pneumonectomy,4 but can potentially occur after any minimally invasive surgery involving a pericardial incision. In this case report, we present 2 cases of cardiac herniation occurring after minimally invasive MV surgery; the 2 cases had different surgical exposures and clinical presentations. Early diagnosis is crucial for a timely lifesaving definitive management. Waiver of patient consent was obtained from IRB because both patients could not be reached.
placed. Successful repair was confirmed by easily acquired standard transesophageal echocardiography (TEE) views (Fig. 1A; Video 1, see Supplemental Digital Content 1, http://links.lww.com/AACR/A2).
CASE DESCRIPTION 1
A 44-year-old man with asymptomatic severe degenerative MV disease and severe mitral regurgitation underwent mitral valvuloplasty through a 4-cm right minithoracotomy. After induction of general anesthesia, a double-lumen tube was placed to facilitate left-sided 1-lung ventilation. The right internal jugular vein was percutaneously cannulated by both 7.5-Fr triple-lumen, and 16-gauge single-lumen catheters. Femoro-femoral CPB was started after femoral arterial and venous cannulation. The pericardium was opened, and a coronary sinus catheter was placed by the surgeon. MV prolapse was repaired, and a Duran ring was From the Departments of *Cardiothoracic Anesthesiology and †Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Accepted for publication April 25, 2013. Funding: Not applicable. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (cases.anesthesia-analgesia.org). Address correspondence to Negmeldeen F. Mamoun, MD, PhD, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, 9500 Euclid Ave./J4-331, Cleveland, OH 44195. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e31829c685d
December 15, 2013 • Volume 1 • Number 6
Figure 1. A, Midesophageal 4-chamber transesophageal echocardiographic (TEE) view obtained at 0° after mitral valve repair and before cardiac herniation. B, Nonstandard TEE view obtained also at 0° after cardiac herniation. C, Midesophageal 4-chamber TEE view after correction of cardiac herniation. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle. cases-anesthesia-analgesia.org
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Cardiac Herniation After Mitral Valve Surgery
Video 1. Transesophageal echocardiographic (TEE) view: midesophageal 4-chamber obtained at 0° after mitral valve repair and before cardiac herniation. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
Video 3. Transesophageal echocardiographic (TEE) view: midesophageal 4-chamber obtained at 0° after correction of cardiac herniation. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
While being moved from the operating room table to the intensive care unit (ICU) bed at the end of surgery, the patient became hypotensive but responded to fluids and intermittent boluses of vasopressors. A TEE probe was replaced for further evaluation of the etiology of hypotension, but we were unable to adequately image the heart with standard midesophageal views (Fig. 1B; Video 2, see Supplemental Digital Content 2, http://links.lww.com/AACR/A3), and completely unable to visualize the heart with transgastric views. The descending aorta was visualized, and no dissection was noted. The chest was reexplored because of continued need for vasopressor support and inability to image the heart adequately. On surgical exposure, the right lung was found to be incompletely inflated and the heart had herniated through the pericardial defect and was twisted over its primary axis into the right hemithorax. After simple manual repositioning of the heart, stable hemodynamics and standard TEE views were restored (Fig. 1C; Video 3, see Supplemental Digital Content 3, http://links.lww.com/AACR/A4); findings were unchanged from the TEE examination done immediately after MV repair. The pericardium was closed with 3 interrupted sutures, and the right lung was reinflated under direct visualization. The patient was transported to the ICU
in stable condition; he was later transferred to the floor on the first postoperative day (POD) and was discharged on the fourth POD after an uneventful hospital course.
CASE DESCRIPTION 2
A 49-year-old man with asymptomatic severe degenerative MV disease and severe mitral regurgitation underwent robotically assisted minimally invasive mitral valvuloplasty through multiple small ports in the right chest. Anesthetic and surgical management was similar to that of the first case with the exception that a coronary sinus catheter was not placed, and only antegrade cardioplegia was delivered. MV repair was successful as confirmed by TEE examination done after CPB; the patient was transported to the ICU after an uneventful intraoperative course. Routine chest radiograph performed on ICU admission revealed herniation of the heart into the right hemithorax (Fig. 2A). The patient was completely asymptomatic, chest radiograph was repeated after leaning the patient toward his left side, but it was unchanged. The patient was transferred back to the operating room, the heart was manually repositioned to its anatomical position, and the pericardial defect was closed with a synthetic patch. A chest radiograph on arrival to the ICU confirmed that cardiac herniation was corrected (Fig. 2B). The patient was transferred to the floor on the first POD and was discharged on the sixth POD after an uneventful hospital course.
DISCUSSION
Video 2. Nonstandard transesophageal echocardiographic (TEE) view obtained at 0° after cardiac herniation. LA = left atrium; LV = left ventricle.
80 cases-anesthesia-analgesia.org
Cardiac herniation is a very rare and dangerous complication with a mortality rate approaching 50%.5 The few recent reports of cardiac herniation after minimally invasive cardiac surgery6–8 all had different clinical presentations. Symptoms depend on the side of cardiac herniation; only right-sided herniation is possible with minimally invasive MV surgery as the pericardium is incised on the right side. Right-sided herniation has a wide spectrum of presentations from asymptomatic to severe hypotension, tachycardia, and superior vena cava syndrome; the presentation usually depends on the degree of impediment of superior and inferior vena caval inflow.9 One of our patients was completely
A & A case reports
Figure 2. A, Chest radiograph with cardiac herniation in the right hemithorax. B, Chest radiograph after cardiac repositioning to its anatomical position.
asymptomatic, while the other exhibited mild hemodynamic instability that was controlled with fluids and vasopressors. Nonspecific symptoms make the diagnosis of cardiac herniation more difficult. However, timely diagnosis is critical because if the patient’s condition deteriorates and cardiopulmonary resuscitation is initiated, chest compressions are useless because the heart is not in its anatomical position. Factors triggering cardiac herniation include a marked increase in intrathoracic pressure, which is usually associated with excessive ventilation of the contralateral lung (e.g., strong positive pressure ventilation when coming off CPB), coughing on extubation, excessive suction from ipsilateral chest tubes, or positioning the side of surgery more dependently.10 In our first case, turning the patient to his right side to place the roller underneath him or the acceleration–deceleration associated with patient movement to the ICU bed likely facilitated herniation of the heart through the open pericardium into the right chest cavity. However, in our second case, the event triggering the herniation is uncertain given that it was asymptomatic and unrecognized until ICU admission. It is important to avoid triggering factors within the first 24 hours after surgery; the vast majority of cardiac herniations have been reported during that time frame. Adhesions tend to form between the pericardium and the heart very quickly, decreasing the incidence of late cardiac herniation.11 Diagnosis of cardiac herniation may be confirmed by chest radiograph revealing a “snow cone” shape of the right border of the heart if herniation is partial or impending,12 or as in our second case, it may reveal a complete herniation with shifting of the cardiac shadow from the left to the right hemithorax. Chest radiograph can also reveal reversal of a pulmonary artery catheter loop and rotation in a clockwise fashion.13 Computed tomography scan,7 magnetic resonance imaging,3 transthoracic echocardiography,11 TEE, and video-assisted thoracoscopy8 have been used in different capacities to diagnose cardiac herniation as well. While hypotension after cardiac surgery is not uncommon, and in our first case initially responded to fluids and vasopressors, it was the inability to image the heart adequately from standard TEE views that alerted our team to the possibility of cardiac herniation, particularly recognizing that standard views were easily acquired a few minutes earlier. Definitive management of cardiac herniation includes surgical exploration to reposition the heart back to its anatomical position and closing the pericardial defect primarily or using synthetic mesh or bovine pericardium. Additional treatment measures include positioning the nonsurgical side more dependently and avoiding hyperinflation of
December 15, 2013 • Volume 1 • Number 6
the contralateral lung.9 It is prudent to routinely close any pericardial defect after minimally invasive cardiac surgery irrespective of how small it is. However, cardiac herniation should always be considered even if the pericardium was repaired; herniation has been reported to happen when the pericardial repair broke in the early postoperative period.14 In this case report, we present 2 patients in whom rightsided cardiac herniation followed minimally invasive mitral valvuloplasty. The 2 examples of herniation had different clinical presentations, which made the diagnosis more difficult. Cardiac herniation is an extremely rare and potentially fatal complication requiring early detection and timely definitive management. E REFERENCES 1. Modi P, Hassan A, Chitwood WR Jr. Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2008;34:943–52 2. Bettman RB, Tannenbaum WJ. Herniation of the heart: through a pericardial incision. Ann Surg 1948;128:1012–4 3. Sohn JH, Song JW, Seo JB, Do KH, Lee JS, Kim DK, Song KS, Lim TH. Case report: pericardial rupture and cardiac herniation after blunt trauma: a case diagnosed using cardiac MRI. Br J Radiol 2005;78:447–9 4. Mehanna MJ, Israel GM, Katigbak M, Rubinowitz AN. Cardiac herniation after right pneumonectomy: case report and review of the literature. J Thorac Imaging 2007;22:280–2 5. Self RJ, Vaughan RS. Acute cardiac herniation after radical pleuropneumonectomy. Anaesthesia 1999;54:564–6 6. Wasir H, Malhotra R, Vats M, Sharma KK, Mehta Y, Trehan N. Cardiac herniation following atrial septal defect closure using port access surgery. Indian Heart J 2006;58:260–2 7. Speggiorin S, Padalino MA, Vida VL, Bonato R, Stellin G. Cardiac herniation after minimally invasive cardiac surgery: an unusual potentially lethal complication. Circulation 2009;120:2509–10 8. Yamaguchi S, Ishikawa N, Watanabe G. Cardiac herniation during robot-assisted cardiac operation. J Thorac Cardiovasc Surg 2012;143:e10–1 9. Cassorla L, Katz JA. Management of cardiac herniation after intrapericardial pneumonectomy. Anesthesiology 1984;60:362–4 10. Shimizu J, Ishida Y, Hirano Y, Tatsuzawa Y, Kawaura Y, Nozawa A, Yamada K, Oda M. Cardiac herniation following intrapericardial pneumonectomy with partial pericardiectomy for advanced lung cancer. Ann Thorac Cardiovasc Surg 2003;9:68–72 11. Nanda S, Pamula J, Bhatt SP, Turki MA, Myers E, Dale T. Cardiac herniation and volvulus with acquired dextrocardia: echocardiographic diagnosis. Echocardiography 2007;24:870–4 12. Gurney JW, Arnold S, Goodman LR. Impending cardiac herniation: the snow cone sign. Radiology 1986;161:653–5 13. Brogdon BG, Georgy BA. An unusual twist. Br J Radiol 1998;71:691–2 14. Veronesi G, Spaggiari L, Solli PG, Pastorino U. Cardiac dislocation after extended pneumonectomy with pericardioplasty. Eur J Cardiothorac Surg 2001;19:89–91
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