Case Study
Blunt traumatic left atrial appendage rupture and cardiac herniation
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(5) 598–600 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313479124 aan.sagepub.com
Nguyen Huu Nhan1, Pham Tho Tuan Anh2, Tran Minh Trung2 and A Thomas Pezzella3
Abstract A 42-year-old man sustained blunt thoracic trauma after a motor vehicle accident. He underwent an urgent operation. Operative findings included a large hematoma, a 4-cm tear in the left atrial appendage, and a long pleuropericardial rupture along the right phrenic nerve. We repaired the left atrial appendage without cardiopulmonary bypass, and closed the pericardial defect primarily. The patient recovered fully and was discharged on the 6th postoperative day.
Keywords Heart rupture, heart Injuries, pericardium, wounds, nonpenetrating
Introduction Blunt cardiac trauma with rupture of the left atrial (LA) appendage and herniation of the heart into the right pleural space through the ruptured posterior pericardium is a rare injury following a motor vehicle accident.1 We describe such a case and give a brief literature review with emphasis on presentation, operative repair, and outcome.
Case report A 42-year-old man, who was riding a motorcycle while intoxicated, suffered a head-on collision with another motorcycle. At the regional hospital, his blood pressure was 90/60 mm Hg, with diminished peripheral pulses. Chest radiography showed a midline trachea, right pleural effusion, dextrocardia, a right clavicular fracture, and a large mass in the left mediastinum (Figure 1). Initial management included normal saline infusion, tetanus antitoxin, and 2 units of packed red blood cells. A right pleural drain was placed, and 850 mL of red blood was drained. Diagnostic peritoneal lavage at the right iliac fossa returned no blood. He was transferred to our hospital 8 h later, awake, alert, oriented, and stable but mildly hypotensive, tachycardic, and tachypneic. There was a palpable right clavicular fracture and superficial bruises over the left abdomen, but no distended neck veins. The chest was symmetric with
no palpable rib fractures, and good respiratory movement bilaterally. Muffled heart sounds were heard, distant on the left, more clearly on the right, with a weak 2/6 systolic murmur at the 3rd and 4th intercostal spaces along the right sternal margin. Breath sounds were clear on the left, with some coarse crackles in the right upper chest. The abdomen was soft, not tender, with no guarding and no rebound tenderness. Two superficial wounds over the right leg were closed in the emergency room. Total chest drainage was 1.1 L of blood. Computed tomography with contrast revealed dextrocardia with a right-sided aortic arch, vena cava, and liver, and a left-sided descending aorta and spleen. There was no injury to the great vessels but a right upper pulmonary contusion and a large hematoma in the left anterior mediastinum that appeared to be pushing the heart to the right (Figure 2). Echocardiography was inconclusive. The patient remained stable over the next 10 h with the chest tube draining a total of 1
Medical and Health Science Center, University of Debrecen, Hungary Department of Cardiac Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam 3 International Children’s Heart Fund, Worcester, MA, USA 2
Corresponding author: A Thomas Pezzella, MD, 17 Shamrock Street, Worcester, MA 01605, USA. Email: [email protected]
Downloaded from aan.sagepub.com at RYERSON UNIV on June 17, 2015
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Figure 1. Initial chest radiograph showing a right clavicular fracture, large right pleural effusion, dextrorotation of the heart, and hemopericardium that outlines the left pericardial silhouette.
Figure 3. Operative photo showing a Statinsky vascular clamp placed at the base of the left atrial appendage. The heart is herniated into the right pleural space via a tear in the pericardium. The head of the patient is at the bottom of the image.
Figure 2. Axial computed tomography slice with contrast enhancement, mediastinal window showing dextrorotation of the heart and a large hemopericardium. The black arrow shows possible left atrial appendage rupture site. AO: aorta; LA: left atrium; LV: left ventricle; LVOT: left ventricular outflow tract; PV: pulmonary vein; RV: right ventricle.
1800 mL at nearly 100 mLh 1. Surgery via a median sternotomy revealed a large hemopericardium and the heart herniated into the right pleural space through a long tear in the pericardium, posterior to the right phrenic nerve. Only the LA appendage and main pulmonary artery remained in the pericardial sac; there was a 2-cm rupture from the base to the tip (Figures 3 and 4). It was clamped at the base carefully to avoid the circumflex artery, and repaired with 5/0 polypropylene suture with Teflon pledget reinforcement, without cardiopulmonary bypass. The heart was returned to the left side (Figure 5). The right phrenic nerve appeared intact. The pericardial defect was closed to avoid recurrent herniation. Operative time was 2 h. The patient was transfused with another 2 units of packed red blood cells.
Figure 4. Operative photo: close-up view of the tear of the pericardium (marked by arrows) and the heart herniated into the right pleural space. The left atrial appendage remained inside the pericardial sac as outlined with a. dashed line. LAA: left atrial appendage.
The postoperative course was uneventful, and he was discharged on the 6th postoperative day.
Discussion The incidence of blunt traumatic right pleuropericardial rupture is very low, and survival after LA appendage and pericardial rupture is rare because the ruptured pericardium does not limit the amount of blood loss into the right chest . Patients with blunt traumatic pericardial and/or chamber rupture tend to sustain multiple trauma.1,2 A PubMed search found 10 isolated case
Downloaded from aan.sagepub.com at RYERSON UNIV on June 17, 2015
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Asian Cardiovascular & Thoracic Annals 22(5)
Figure 5. Operative photograph showing the heart returned to its normal position.
reports of blunt traumatic LA/pulmonary vein rupture in patients who survived to hospital admission, 90% survived surgery. Common causes of cardiac rupture are traffic accidents, falls, skiing, and animal kicks.1,3,4 Most patients sustain multiple injuries. Commonly associated injuries are extremity, rib, spine, and cranium fractures, traumatic brain injury, pulmonary contusion, and hepatic and splenic lacerations.4–6 The most common rupture sites are the left and right pleuropericardium and the diaphragmatic pericardium. The heart is usually herniated into the left pleural space. Clinical signs most often described are sudden or intermittent signs and symptoms of pericardial tamponade with hypotension, tachycardia, jugular venous distention, and ‘‘bruit de moulin’’ (a murmur presumed to be the heart beating in the blood-filled pericardial sac).1 However, we presume our patient’s murmur was caused by variable degrees of outflow tract obstruction from compression and twisting of the aorta and main pulmonary artery. Our patient was stable hemodynamically throughout the observation period. Differential diagnoses include isolated dextrocardia or preexisting pericardial conditions that caused the heart to rotate to the right, possibly tuberculosis or a mediastinal tumor. Chest computed tomography with contrast is valuable to clarify the anatomy, confirm that the mass occupying the left mediastinum is blood, and pinpoint the possible site of chamber rupture. However, the contrast-leak sign was not obvious in this case (Figure 2). LA rupture was diagnosed and urgent surgery was recommended. We performed a median sternotomy for better cardiac and major vessel control, and prepared the left femoral vessels for cardiopulmonary bypass. Concurrent LA and pericardial rupture with cardiac herniation is usually fatal. The only explanation for our
patient’s survival was that the pericardial rupture prevented cardiac tamponade; the extensive tear in the pericardium enabled the heart to swing freely, preventing torsion and strangulation. The low-pressure LA appendage rupture was partially occluded by a blood clot in the pericardium, and possibly, the torn edge of the pericardium partially isolated the ruptured LA appendage; these 2 factors combined to prevent early exsanguination. However, with each heartbeat and movement of the patient, varying amounts of blood could spill out, which explains the slow but continuous chest tube drainage. Had we carried out a right thoracotomy, we would have found the heart herniated into the right pleural space, and possibly missed the LA tear. In this case, extending the incision across the sternum would improve exposure and give access to the pericardial sac and posterior pericardial structures. The femoral vessels should be prepared for cardiopulmonary bypass. The pericardial defect should be closed when it is large enough to cause herniation and hemodynamic collapse, especially on the right side. The diagnosis of blunt traumatic cardiac rupture requires a high index of suspicion. The management should be close monitoring with special attention to hemodynamic status, and proceeding to emergency surgery immediately once suspected. A median sternotomy provides good exposure and control of all cardiac chambers and the great vessels.1,2,5 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM and Cowley RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989). J Trauma 1991; 31: 167–172. 2. Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM and Cowley R. Blunt traumatic cardiac rupture. A 5-year experience. Ann Surg 1990; 212: 701–704. 3. Lancey RA and Monahan TS. Correlation of clinical characteristics and outcomes with injury scoring in blunt cardiac trauma. J Trauma 2003; 54: 509–515. 4. Parmley LF, Manion WC and Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958; 18: 371–396. 5. Nan YY, Lu MS, Liu KS, Huang YK, Tsai FC, Chu JJ and Lin PJ. Blunt traumatic cardiac rupture: therapeutic options and outcomes. Injury 2009; 40: 938–945. 6. Schultz JM and Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004; 20: 57–70.
Downloaded from aan.sagepub.com at RYERSON UNIV on June 17, 2015
Blunt traumatic left atrial appendage rupture and cardiac herniation
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(5) 598–600 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313479124 aan.sagepub.com
Nguyen Huu Nhan1, Pham Tho Tuan Anh2, Tran Minh Trung2 and A Thomas Pezzella3
Abstract A 42-year-old man sustained blunt thoracic trauma after a motor vehicle accident. He underwent an urgent operation. Operative findings included a large hematoma, a 4-cm tear in the left atrial appendage, and a long pleuropericardial rupture along the right phrenic nerve. We repaired the left atrial appendage without cardiopulmonary bypass, and closed the pericardial defect primarily. The patient recovered fully and was discharged on the 6th postoperative day.
Keywords Heart rupture, heart Injuries, pericardium, wounds, nonpenetrating
Introduction Blunt cardiac trauma with rupture of the left atrial (LA) appendage and herniation of the heart into the right pleural space through the ruptured posterior pericardium is a rare injury following a motor vehicle accident.1 We describe such a case and give a brief literature review with emphasis on presentation, operative repair, and outcome.
Case report A 42-year-old man, who was riding a motorcycle while intoxicated, suffered a head-on collision with another motorcycle. At the regional hospital, his blood pressure was 90/60 mm Hg, with diminished peripheral pulses. Chest radiography showed a midline trachea, right pleural effusion, dextrocardia, a right clavicular fracture, and a large mass in the left mediastinum (Figure 1). Initial management included normal saline infusion, tetanus antitoxin, and 2 units of packed red blood cells. A right pleural drain was placed, and 850 mL of red blood was drained. Diagnostic peritoneal lavage at the right iliac fossa returned no blood. He was transferred to our hospital 8 h later, awake, alert, oriented, and stable but mildly hypotensive, tachycardic, and tachypneic. There was a palpable right clavicular fracture and superficial bruises over the left abdomen, but no distended neck veins. The chest was symmetric with
no palpable rib fractures, and good respiratory movement bilaterally. Muffled heart sounds were heard, distant on the left, more clearly on the right, with a weak 2/6 systolic murmur at the 3rd and 4th intercostal spaces along the right sternal margin. Breath sounds were clear on the left, with some coarse crackles in the right upper chest. The abdomen was soft, not tender, with no guarding and no rebound tenderness. Two superficial wounds over the right leg were closed in the emergency room. Total chest drainage was 1.1 L of blood. Computed tomography with contrast revealed dextrocardia with a right-sided aortic arch, vena cava, and liver, and a left-sided descending aorta and spleen. There was no injury to the great vessels but a right upper pulmonary contusion and a large hematoma in the left anterior mediastinum that appeared to be pushing the heart to the right (Figure 2). Echocardiography was inconclusive. The patient remained stable over the next 10 h with the chest tube draining a total of 1
Medical and Health Science Center, University of Debrecen, Hungary Department of Cardiac Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam 3 International Children’s Heart Fund, Worcester, MA, USA 2
Corresponding author: A Thomas Pezzella, MD, 17 Shamrock Street, Worcester, MA 01605, USA. Email: [email protected]
Downloaded from aan.sagepub.com at RYERSON UNIV on June 17, 2015
Nhan et al.
599
Figure 1. Initial chest radiograph showing a right clavicular fracture, large right pleural effusion, dextrorotation of the heart, and hemopericardium that outlines the left pericardial silhouette.
Figure 3. Operative photo showing a Statinsky vascular clamp placed at the base of the left atrial appendage. The heart is herniated into the right pleural space via a tear in the pericardium. The head of the patient is at the bottom of the image.
Figure 2. Axial computed tomography slice with contrast enhancement, mediastinal window showing dextrorotation of the heart and a large hemopericardium. The black arrow shows possible left atrial appendage rupture site. AO: aorta; LA: left atrium; LV: left ventricle; LVOT: left ventricular outflow tract; PV: pulmonary vein; RV: right ventricle.
1800 mL at nearly 100 mLh 1. Surgery via a median sternotomy revealed a large hemopericardium and the heart herniated into the right pleural space through a long tear in the pericardium, posterior to the right phrenic nerve. Only the LA appendage and main pulmonary artery remained in the pericardial sac; there was a 2-cm rupture from the base to the tip (Figures 3 and 4). It was clamped at the base carefully to avoid the circumflex artery, and repaired with 5/0 polypropylene suture with Teflon pledget reinforcement, without cardiopulmonary bypass. The heart was returned to the left side (Figure 5). The right phrenic nerve appeared intact. The pericardial defect was closed to avoid recurrent herniation. Operative time was 2 h. The patient was transfused with another 2 units of packed red blood cells.
Figure 4. Operative photo: close-up view of the tear of the pericardium (marked by arrows) and the heart herniated into the right pleural space. The left atrial appendage remained inside the pericardial sac as outlined with a. dashed line. LAA: left atrial appendage.
The postoperative course was uneventful, and he was discharged on the 6th postoperative day.
Discussion The incidence of blunt traumatic right pleuropericardial rupture is very low, and survival after LA appendage and pericardial rupture is rare because the ruptured pericardium does not limit the amount of blood loss into the right chest . Patients with blunt traumatic pericardial and/or chamber rupture tend to sustain multiple trauma.1,2 A PubMed search found 10 isolated case
Downloaded from aan.sagepub.com at RYERSON UNIV on June 17, 2015
600
Asian Cardiovascular & Thoracic Annals 22(5)
Figure 5. Operative photograph showing the heart returned to its normal position.
reports of blunt traumatic LA/pulmonary vein rupture in patients who survived to hospital admission, 90% survived surgery. Common causes of cardiac rupture are traffic accidents, falls, skiing, and animal kicks.1,3,4 Most patients sustain multiple injuries. Commonly associated injuries are extremity, rib, spine, and cranium fractures, traumatic brain injury, pulmonary contusion, and hepatic and splenic lacerations.4–6 The most common rupture sites are the left and right pleuropericardium and the diaphragmatic pericardium. The heart is usually herniated into the left pleural space. Clinical signs most often described are sudden or intermittent signs and symptoms of pericardial tamponade with hypotension, tachycardia, jugular venous distention, and ‘‘bruit de moulin’’ (a murmur presumed to be the heart beating in the blood-filled pericardial sac).1 However, we presume our patient’s murmur was caused by variable degrees of outflow tract obstruction from compression and twisting of the aorta and main pulmonary artery. Our patient was stable hemodynamically throughout the observation period. Differential diagnoses include isolated dextrocardia or preexisting pericardial conditions that caused the heart to rotate to the right, possibly tuberculosis or a mediastinal tumor. Chest computed tomography with contrast is valuable to clarify the anatomy, confirm that the mass occupying the left mediastinum is blood, and pinpoint the possible site of chamber rupture. However, the contrast-leak sign was not obvious in this case (Figure 2). LA rupture was diagnosed and urgent surgery was recommended. We performed a median sternotomy for better cardiac and major vessel control, and prepared the left femoral vessels for cardiopulmonary bypass. Concurrent LA and pericardial rupture with cardiac herniation is usually fatal. The only explanation for our
patient’s survival was that the pericardial rupture prevented cardiac tamponade; the extensive tear in the pericardium enabled the heart to swing freely, preventing torsion and strangulation. The low-pressure LA appendage rupture was partially occluded by a blood clot in the pericardium, and possibly, the torn edge of the pericardium partially isolated the ruptured LA appendage; these 2 factors combined to prevent early exsanguination. However, with each heartbeat and movement of the patient, varying amounts of blood could spill out, which explains the slow but continuous chest tube drainage. Had we carried out a right thoracotomy, we would have found the heart herniated into the right pleural space, and possibly missed the LA tear. In this case, extending the incision across the sternum would improve exposure and give access to the pericardial sac and posterior pericardial structures. The femoral vessels should be prepared for cardiopulmonary bypass. The pericardial defect should be closed when it is large enough to cause herniation and hemodynamic collapse, especially on the right side. The diagnosis of blunt traumatic cardiac rupture requires a high index of suspicion. The management should be close monitoring with special attention to hemodynamic status, and proceeding to emergency surgery immediately once suspected. A median sternotomy provides good exposure and control of all cardiac chambers and the great vessels.1,2,5 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM and Cowley RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989). J Trauma 1991; 31: 167–172. 2. Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM and Cowley R. Blunt traumatic cardiac rupture. A 5-year experience. Ann Surg 1990; 212: 701–704. 3. Lancey RA and Monahan TS. Correlation of clinical characteristics and outcomes with injury scoring in blunt cardiac trauma. J Trauma 2003; 54: 509–515. 4. Parmley LF, Manion WC and Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958; 18: 371–396. 5. Nan YY, Lu MS, Liu KS, Huang YK, Tsai FC, Chu JJ and Lin PJ. Blunt traumatic cardiac rupture: therapeutic options and outcomes. Injury 2009; 40: 938–945. 6. Schultz JM and Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004; 20: 57–70.
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