Ann Thorac Surg 2004;78:1095-1097
© 2004 The Society of Thoracic Surgeons
Case report
Sudden cardiac herniation 6 months after right pneumonectomy
Friso T. Zandberg, MDa,b,*,
Stephen J. M. E. Verbeke, MDa,b,
Repke J. Snijder, MDa,b,
Willem H. Dalinghaus, MDa,b,
Simone M. Roeffel, MDa,b,
Henry A. Van Swieten, MD, PhDa,b
a Departments of Pulmonology and Cardiothoracic Surgery, Heart Lung Center Utrecht, St. Antonius Hospital, Nieuwegein, The Netherlands
b Departments of Pulmonology and Cardiology, Meander Medical Center, Amersfoort, The Netherlands
Accepted for publication June 25, 2003.
* Address reprint requests to Dr Zandberg, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
kuilberg{at}planet.nl
 |
Abstract
|
|---|
Cardiac herniation is a rare complication of intrapericardial pneumonectomy and has a high mortality. The condition has been reported only within 24 hours after surgery. In this report, a case is described in which a total cardiac herniation took place 6 months after right intrapericardial pneumonectomy. The patient presented with an acute vena cava superior syndrome and underwent thoracotomy to reposition the heart into the pericardial sac and to close the pericardium with a patch.
|
Introduction
|
|---|
Sudden herniation of the heart 6 months after intrapericardial pneumonectomy presenting with a vena cava superior syndrome has not been described before. It has been reported only in the early postoperative period after pneumonectomy [1 and 2]. The diagnosis should be made quickly because of the life-threatening situation caused by torsion of the superior caval vein, a decreased filling of the right atrium, and a fall in the cardiac output. Urgent thoracotomy for reposition and fixation of the heart has to be performed.
A 33-year-old man was transferred, with a delay of 40 hours since the first symptoms, from a local hospital where he had been admitted with an acute vena cava superior syndrome. Six months earlier, he underwent a right-sided intrapericardial pneumonectomy because of non–small lung cancer stage T2N1 M0. The pneumonectomy had to be intrapericardial because the tumor was centrally located and attached to the right pulmonary artery. The pericardial defect was left open. A few hours before presentation at the first hospital, the patient felt a "crack" in his chest while walking the stairs after he had been vacuuming. Immediately, his head and upper chest became blue, accompanied with pain in the chest and dyspnea. Physical examination revealed an obvious vena cava superior syndrome and heart sounds in the right upper part of the chest. The patient was stable with a blood pressure of 110/75 mm Hg, a heart rate of 112 beats per minute, and oxygen saturation of 95%. The differential diagnosis consisted of cardiac herniation or recurrent carcinoma compressing the superior caval vein. The laboratory results showed elevated troponine I (maximum, 14.6 µg/L; normal, < 0.2 µg/L) and elevated CKs (maximum, 1,061 IU/L and CK-MB 62 IU/L). Chest radiography showed a displacement of the heart to the right, which was not seen on former chest radiographs (Fig 1). The computed tomography scan, performed with contrast injected into the right arm, revealed a displacement of the heart into the right hemithorax and an obstruction of the superior caval vein with backflow into the azygos vein. No pathologic mass was seen. The major airways were open. The electrocardiogram showed a sinus rhythm and an extreme right axis deviation with a dominant R-wave in V1, without repolarization disturbances in the other leads. A transthoracic echocardiogram performed at the right lateral side of the chest showed an important inflow limitation through the inferior caval vein to the right atrium and an absence of flow in the superior caval vein; right and left ventricular function seemed normal and no pericardial effusion was seen. Approximately 48 hours after the first symptoms, the patient underwent a limited right anterolateral thoracotomy, which showed a complete herniation of the heart through the pericardium, volvulus of the dilated heart, and torsion of the great veins leading to the right atrium. A large part of the pericardium posterior of the phrenic nerve had been removed during intrapericardial pneumonectomy 6 months before. Fibrosis was present only locally around the pericardial defect, and an additional fresh tear was seen. This was the reason for the herniation. The heart was replaced in the pericardium by means of a retraction suture on the anterior edge of the pericardium, pulling of the suture, and pulling of the apex of the heart. This maneuver caused a sharp drop of blood pressure during a short period; hemodynamics recovered fast, but the heart still showed dilation. No signs of local tumor recurrence were seen. The pericardium was closed with an expanded polytetrafluoroethylene pericardial membrane (Preclude, W.L. Gore & Associates; Flagstaff; AZ). Immediately after the operation, the vena cava superior syndrome disappeared and the patient recovered well. Eight months later, the patient presented with disseminated disease with metastases in the trachea and bone.
View larger version (99K):
[in this window]
[in a new window]
|
Fig 1. Chest radiograph showing that the cardiac contour disappeared in the filled right hemithorax after pneumonectomy.
|
|
|
Comment
|
|---|
In special cases of centrally advanced lung tumors, an intrapericardial pneumonectomy must be performed to achieve a complete resection. Cardiac herniation is a rare, mostly lethal complication [1, 2]. The condition presents in the immediate or early postoperative period. Cardiovascular collapse is invariably present. Elevation of the jugular venous pressure and cyanosis in the drainage area of the superior caval vein are frequently noted [3–6] and ventricular fibrillation may occur [7]. Treatment is emergency thoracotomy with reposition of the herniated heart into the pericardial sac and repairing the defect of the pericardium [2]. Most documented cases of cardiac herniation have occurred through surgically created defects as a result of intrapericardial pneumonectomy or lobectomy with partial pericardectomy. Fatal herniations have been reported through congenital defects, through pericardial tears, or as a result of severe blunt trauma of the chest [1]. The late herniation of the heart as occurred in our patient has not been described. Our patient was hemodynamic compromised but stable for 48 hours. Probably, this was due to the fact that the patient underwent the pneumonectomy 6 months earlier, after which he became adapted to the one lung circulation. The late herniation possibly took place because the pericardium was not healed properly and the patient resumed his heavy physical work too soon. He had to lift heavy crates, being a market trader selling fish. Or perhaps the heart partially herniated from the pericardium in the immediate postoperative period without any serious hemodynamic effect, followed by a sudden complete herniation after 6 months. The rise of the cardiac enzymes is probably due to contusion of the heart because of deviation and torsion. The dilation of the heart that was seen during the operation can be the result of the cardiac contusion and prolonged disturbed hemodynamics from which the heart did not recover immediately after repositioning.
This case illustrates that the combination of a sudden vena cava superior syndrome and heart sounds in the right side of the chest should alert the physician to the possibility of cardiac herniation, even 6 months after intrapericardial pneumonectomy. We believe that surgical defects of the pericardium as a result of right intrapericardial pneumonectomy should be closed. This can be accomplished either by suturing the cut edges of the pericardium to the epicardium or by patching the defect with artificial material, parietal pleura, or fascia lata. In cases of left pneumonectomy, it may be sufficient to enlarge the pericardial defect in order to prevent strangulation, should herniation occur [8].
|
References
|
|---|
- Deiraniya AK. Cardiac herniation following intrapericardial pneumonectomy. Thorax. 1974;29:545–552[Abstract/Free Full Text]
- Yacoub MH, Williams WG, Ahmad A. Strangulation of the heart following intrapericardial pneumonectomy. Thorax. 1968;23:261–265[Abstract/Free Full Text]
- Vanoverbeke HM, Schepens MA, Knaepen PJ. Acute cardiac herniation following intrapericardial pneumonectomy. Acta Chir Belg. 1998;98:98–100[Medline]
- Arndt RD, Frank CG, Schmitz AL, Haveson SB. Cardiac herniation with volvulus after pneumonectomy. Am J Roentgenol. 1978;130:155–156[Medline]
- Rodenwaldt J, Lembcke AE, Wiese TH, Höhn S, Hamm BK. Postoperative dislocation of the heart after pneumonectomy. Circulation. 2002;105:49–50
- Gurney JW, Arnold S, Goodman LR. Impending cardiac herniation: the snow cone sign. Radiology. 1986;161:653–655[Abstract/Free Full Text]
- Montero CA, Gimferrer JM, Fita G, Serra M, Catalán M, Canalís E. Unexpected postoperative course after right pneumonectomy. Chest. 2000;117:1184–1185[Free Full Text]
- Papsin BC, Gorenstein LA, Goldberg M. Delayed myocardial laceration after intrapericardial pneumonectomy. Ann Thorac Surg. 1993;55:756–757[Abstract]
This article has been cited by other articles:
|
|
|
|
 
C. Soll, D. Hahnloser, T. Frauenfelder, E. W. Russi, W. Weder, and P. B. Kestenholz
The postpneumonectomy syndrome: clinical presentation and treatment
Eur. J. Cardiothorac. Surg.,
February 1, 2009;
35(2):
319 - 324.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
