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Ann Thorac Surg 2003;75:581-582
© 2003 The Society of Thoracic Surgeons

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Case report

Pericardial rupture and cardiac herniation after blunt chest trauma

^a Department of Cardiothoracic Surgery, Tygerberg Hospital, University of Stellenbosch, Tygerberg, South Africa

Accepted for publication August 14, 2002.

* Address reprint requests to Dr Janson, Department of Cardiothoracic Surgery, Faculty of Medicine, PO Box 19173, Tygerberg 7505, South Africa
e-mail: jjanson{at}absamail.co.za

	Abstract

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Pericardial rupture after blunt chest trauma is rare and is associated with a high mortality rate. We describe a patient with traumatic pericardial rupture and cardiac herniation who was successfully treated surgically. Traumatic pericardial rupture is difficult to diagnose preoperatively but should be suspected whenever there is severe blunt chest trauma. If pericardial rupture is not recognized and treated promptly it could be fatal owing to cardiac herniation.

	Introduction

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Pericardial rupture after blunt chest trauma is relatively rare. It is most often associated with other major injuries and is usually only diagnosed postmortem [1]. However, during the last 30 to 40 years isolated case reports and small series have shown that traumatic rupture of the pericardium is not always fatal [2]. It is important to recognize this injury to prevent such complications as cardiac herniation [3]. We present a case of traumatic pericardial rupture and subsequent herniation of the heart into the right pleural space.

A 56-year-old man was transferred to our trauma unit from a peripheral hospital about 4 hours after he was hit by a car. He sustained a head injury and had a Glasgow Coma Scale score of 7/15 upon admission. Associated injuries included nine rib fractures on the right and a right intertrochanteric femur fracture. His blood pressure was 70/40 mm Hg at the peripheral hospital with a saturation of 92% on a 40% face mask. Mechanical ventilation was initiated for the flail chest and deteriorating oxygen saturation. The blood pressure responded well to fluid resuscitation.

The initial chest roentgenogram at our trauma unit showed multiple rib fractures on the right side with lung contusion. There was no hemothorax or pneumothorax but a pneumopericardium was visible (Fig 1). Prophylactic chest drains were inserted bilaterally for the multiple rib fractures. The chest roentgenogram changed dramatically after the intercostal drains were placed (Fig 2). The heart herniated into the right pleural cavity. In spite of this the patient remained stable. A rupture of the pericardium was suspected and the patient was prepared for surgery.

View larger version (138K): [in this window] [in a new window]   Fig 1. Chest roentgenogram showing the multiple rib fractures on the right and a pneumopericardium.

View larger version (137K): [in this window] [in a new window]   Fig 2. Chest roentgenogram after insertion of bilateral chest drains showing herniation of the heart into the right pleural cavity.

The patient was hemodynamically unstable during the procedure and required an epinephrine infusion and further ventilation in the intensive care unit. Postoperative echocardiography showed no other cardiac injuries. The femur was fixed 2 days later. The patient’s stay in the intensive care unit was complicated by episodes of atrial fibrillation and a pneumonia. He regained consciousness after 7 days, was extubated on day 12, and was discharged from intensive care on day 14. After 24 days the patient was discharged to the peripheral hospital for rehabilitation. He recovered and 1 year later was still well.

	Comment

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Blunt traumatic rupture of the heart or pericardium is a rare clinical finding but always indicative of an injury severe enough to crush the thoracic cage [3]. Most patients never reach the hospital and those who do often have severe associated injuries [2]. A pericardial rupture should be suspected in a patient with severe blunt trauma to the chest [5]. Clinically it is difficult to diagnose but there are a few clues that need to be sought out. In 1864 Morel-Lavallee reported a murmur sounding like a splashing mill wheel ("bruit de moulin") in a patient with a pericardial rupture. The murmur is caused by the heart beating in a hemopneumopericardium [2].

Pericardial rupture can occur at two different sites, namely the diaphragmatic pericardium and the pleuropericardium [5]. If the diaphragmatic pericardium is injured the abdominal contents may herniate into the pericardial sac and cause cardiac compression with cardiogenic shock. If the pleural pericardium is ruptured the heart may herniate into one of the pleural spaces resulting in heart constriction, strangulation, or torsion of one of the great vessels [4]. Combined pleuropericardial and diaphragmatic tears have also been described. Most common are left pleuropericardial tears, followed by diaphragmatic and right pleuropericardial tears [3]. A few cases of delayed cardiac herniation months or years after the traumatic event have been reported [3, 4].

A chest plain x-ray film is a good screening test for pericardial tears. Pneumopericardium and displacement of the heart may be present as in our case. Bowel gas in the pericardial sac may be indicative of a diaphragmatic tear [5]. Electrocardiography may show axis deviation to the side of the cardiac herniation [1]. There may also be ST-segment changes or a right bundle branch block. This may be from herniation or myocardial contusion [1].

Every patient with a pericardial tear should be evaluated for other cardiac injuries with echocardiography. Clark and coworkers [3] reported tricuspid valve injuries in 3% of patients. Computed tomography scanning of the chest is useful to diagnose a pericardial tear and to rule out aortic injury when the mediastinum is widened [6]. This is however not routinely used as these patients are often too unstable to be transported to the computed tomography scanner.

The diagnosis of most pericardial ruptures is made intraoperatively as an incidental finding [4]. A subxiphoid pericardial window can be done to diagnose a suspected pericardial injury [2]. Blood found in the pericardial space is an indication of a cardiac or pericardial injury and conversion to a sternotomy is necessary. If no blood is aspirated a pericardial lavage is performed. Saline (150 mL) is instilled into the pericardial sac and the fluid is recovered. Retrieval of bloody fluid or failure to recover fluid is suggestive of a pericardial injury.

Once pericardial rupture is recognized, treatment is relatively simple and effective. A median sternotomy gives adequate exposure in most cases. We elected to do a right anterior thoracotomy because of the initial pneumopericardium (Fig 1). We were concerned about an associated tracheobrochial injury and this incision gave good exposure of the main airways and ruptured pericardium. Pericardial closure with nonabsorbable interrupted sutures is usually all that is needed. A small opening should be left for drainage. A defect in the pericardium can be closed with a Dacron or polytetrafluoroethylene patch [2, 4].

The prognosis of these patients depends on the management of their associated cardiac contusion and other injuries. If, however, the pericardial rupture is not recognized and treated it could be life threatening due to cardiac herniation [3, 5].

	References

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1. Mattila S., Silvola H., Ketonen P. Traumatic rupture of the pericardium with luxation of the heart. J Thorac Cardiovasc Surg 1975;70:495-498.[Abstract]
2. Fulda G., Brathwaite C.E.M., Rodriquez A., Turney S.Z., Dunham C.M., Cowley R.A. Blunt traumatic rupture of the heart and pericardium: a ten year experience (1979-1989). J Trauma 1991;31:167-173.[Medline]
3. Clark D.E., Wiles C.S., Lim M.K., Dunham C.M., Rodriquez A. Traumatic rupture of the pericardium. Surgery 1983;93:495-503.[Medline]
4. Watkins B.M., Bucley D.C., Peshiera J.L. Delayed presentation of pericardial rupture with luxation of the heart following blunt trauma: a case report. J Trauma 1995;38:368-369.[Medline]
5. Borrie J., Lichter I. Pericardial rupture from blunt chest trauma. Thorax 1979;29:329-337.[Abstract/Free Full Text]
6. Place R.J., Cavanaugh D.G. Computed tomography to diagnose pericardial rupture. J Trauma 1995;38:822-823.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Janson, J. T. Articles by Rossouw, G. J. Search for Related Content PubMed PubMed Citation Articles by Janson, J. T. Articles by Rossouw, G. J. Related Collections Pericardium