Case Report 379
Traumatic Herniation of the Heart Into the Right Pleura R. Fasol', K, Lotoka' , G. Noldqe', and V. Sc hlosse r' Dep artment of Cardiovasc ular Surge ry Department of Anaesthesia, University of Freiburg. German y
Summary This case repo rt summarizes our experience with a 19-yea r-old male patie nt who suffere d a blun t ches t trau ma during a tr affic accident. On a dm ission no se rious injuries could be detected . but 12 hou rs la ter displa cemen t of the hea rt to th e rig ht side combined with sudden ca rd iac failur e a ppeared . Emergency operation showed a right -sid ed rupture th e pericardium with complete hern ia tion of' thc heart into th e right pleural cavity and consequen t strang ulatio n by th e perica rdia\ m argin.
or
Traumatische Pe rikard ruptur mit bedrohl icher Herz ver-lagerung in die rech te Pleurahtihle Diese Fallbese hre ibung schildert die Diag nose und Th erapi e cines 19ja hr igen Patienten . der im Verla uf eines Verkeh rsun falls von einem Las twage n gege n c ine Mau er gedriickt w urde
In troduction
Herni ation of the heart following sta b wounds, as well as congenital pericardia! defects - especially involving the left ventr icular part of the pericardium - a re seldo m but nevertheless well known and described (I, 5). Isolated pericardial rupture with subse quent herniation of the heart into the right pleura. with no injury to the heart and no clinically relevant symptoms at a dmiss ion, is a rarely known occasion to be seen after blunt chest trauma (3) .
This manuscript describ es our experience in dia gnosis and treatm ent of a patient with traumatic herniati on of the beart into the right pleura through a per icardia I rupture ca used by a traffic accident. Case Report A 19-yea r-old male pa tient suffered a blunt chest trau ma after being rammed by a truck and pr essed aga inst a wa ll d ur ing a tra ffic accident. The pati ent was admitted a short while later to th e trau ma unit after having been intu bated by the attending med ical person nel d uring tra ns portation by helicopter. On a dmiss ion . no serious lifeth reatening inju ries could be detected , except two fra ctu red ribs a nd a righ t sided hem oth orax which was subseque ntly t reated by insertion of a ches t dr ain. Hadi ological and ca rdiologi cal diagnostic proced ures includ ing transoesopha gea l echo showe d no furth er signs of serious injury. CK-MB enzy me and electroca rdiogra m (61show ed no sig ns of cardiac contusion . The patient was tr an sferred to the intens ive care unit for fur th er recovery.
Thorae. cardiovasc. Surgeon 38 (1990 ) 379 - 380 © Georg Thieme Verlag Stuttgart New York
und ein stumpfes Thor ax-Tra um a er litte n hatte. Nac h der Splta lsaufna hmc kon ntcn mit Ausna hme cines rec htsseitigen l lam atoth ora x und Hippen fra ktu ren kei ne ern st ha f't en Vorletzungen dia gn ostiziert we rden . 12 Stunden spatcr tra ten klinische Zeiche n der ll erztam ponade a uf. und in der Thor ax-Ober sichtsaufna hme kon nte cine Verlageru ng des Horzschattons a uf die recht e Soite gosobcn worden . In der na chfolgen de n Notfallop era tion fa nd sich cine Huptu r des Perikardsackes an der re chte n Umschlagfalt e mit einer kompletten Verlagerung des Hcr zens in die rechte Pleu ra und Stra ngulat ion du rch die Perikard ra nde r . Das Herz konnte kc mplik ationsfrei re poniert und das Per ikard versch lossen we rden . Key words Blunt chest tr aum a - Per ica rdia! rupture - Ilernia tion of the heart
Tw elve hou rs after ad mission sudden signs cha ract er ist ic of card iac tam ponade a rose, includ ing a rising central ven ous pressur e and a low cardiac output. Radi ogra phic investigation showed a displacemen t of the hea rt to the right side ('-:ig. 1)a nd the hea rt beat was pa lpa ble on t he right side of the sternum. Eme rgenc y cardiac surgery was perfor med according to the usua l hosp ita l ro utine . Followin g ste rnotomy. careful ins pection 01' the mediastinu m was done : a retros ternal hematoma was found, a nd the perica rdium was ope ned by incisio n. Most strikingly the pericardial bag wa s found tota lly empty (Fig. 21 but with a righ tside d posterior rupt ure ofthe perica rd ium. The hea rt was found to be rotated and complete ly hern ia ted int o the righ t pleural ca vity a nd the margins of the perd icardi um we re ca usi ng a bri dle stricture of the pulmonary art ery as well as the caval veins. The heart was placed back into nor ma l pos ition in the perica rdia! bag and the peri card ial defect then close d by continuo us suture. The postoper a tive cours e was free of a ny kind of ca rdiac comp lications . Postoperative echo showed a normal left vent ricular function and no da mage caused to th e valve s.
Discussion
Peric ardial defects are a seldom congenital malform ation and may resu lt in herniati on of the heart which may ca use stra ngulation an d subsequent symptoms (7). Clinically. complete or partial pericardial defects are describ ed to be acco mpanied with retrosternal pain , syncopes, cardiac a rrhythmia. an d even sudden ca rdiac death (7). Means of diagno sis in such patient s are echoca rd iogra phy (9) and computer tomo graph y [l O), as well as jugular phlebograms (8) .
Received for Publi ca tion : J une 18. 1990
Downloaded by: University of British Columbia. Copyrighted material.
I
2
Thora c. card iov asc. Su rgeon 38 (19 90)
Fig. 1 Chestradiograph showi nga displacement ofthe heartto the rightside, following the sudden appearance of cardiac failure 12 hours after admission
R. Fasol , K. Louika . G. Noldqe , and V. Sch loss er
Fig.2a Intraoperativephotograph demonstratingthe empty pericardial bag witha right sided.posteriorruptu re ofthe pericardium.The heart is rotated and completelyherniated into the right pleural cavity
Pati ents with tra umatic cardiac injury or a blunt chest trauma wit h subse quent ca rd iac cont usion are normally admitted in a serious state whi ch obviousl y requires imm ediate treatme nt (2, 4). In contrast, th e diag nosis of isolated pericardial ruptu re following blunt trauma ma y be difficult, if all diagnostic pr ocedur es show no signs of serious injury on admission . In dealing with suc h patients, initial assessme nt of isolated per icardial rup ture may be tri cky: the clinical symptoms of the herniati on and st ra ngu lation of the heart ap peared in our patien t 12 hours after the eve nt. The real source of sudden cardiac failure could not be proven in our pa tient until surgical explora tion of the pericardium, over lookin g of this type of injury ma y have ea sily occurre d. This expe rience is a warning that the unusual complication of isolated pericardial ruptur e cause d by blunt che st trauma may have delayed results not signalled in initial exte ns ive diagnostic pro cedur es. References
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A mi ri, A .. Ch. Weber. V. Sc hlosse r. and T. H. Mein ertz: Coronary
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Artery Disease in a Patient with a Congenital Pericard ial Defect. Thora c. Cardiovasc. Surgeon 37 (1989) 379-38 1 Bogers . A. 1. J. C . D. J. Zuieers, E. M. Vroom. and H. A. Huy sm an s: Cardiac S ublux atio n in Traumatic Rup tur e of Diaphragm and Pericardium. Thora c. Cardiovasc. S urgeo n 34 (1986) 132- 134 Cliffo rd. R. P.. and K. S. Gill: Trau mat ic ruptur e of the pericardium with dislocation of the heart. Injury 16 (1984) 123 Fasol, R.. P. Zilla. and S. Irvine: Thoracoa bdominal injuri es in combat casualties on the Cambodian border. Thorac . Cardiovasc. Surgeon 36 (1988) 33 Hermann. H.. A. E. Raizer. R. A . Chahine , and R. J. Luchi: Congenital absence of the pericardium. South . Med. J . 69 (1976) 1222 Kettun en. P.: Cardiac damage after blunt chest trauma. diagnosed using CK-M B enzyme and electrocardiogra m. Int. J . Cardiol. 6 (1984) 355 l.equ errier, A .. 1. Mi lon, et D. Milon : Les agenesies du pericarde gauche. Bull. Ass. Anat. 63 (1987) 479 Ma ts uhisa, M.. S. Beppu, and K. S himonura : Postur al effects in the jugular phlebogram in patients with complete absence of the left pericar dium. J . Cardiogr. 16 (1986) 699
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Traumatic Herniation of the Heart Into the Right Pleura R. Fasol', K, Lotoka' , G. Noldqe', and V. Sc hlosse r' Dep artment of Cardiovasc ular Surge ry Department of Anaesthesia, University of Freiburg. German y
Summary This case repo rt summarizes our experience with a 19-yea r-old male patie nt who suffere d a blun t ches t trau ma during a tr affic accident. On a dm ission no se rious injuries could be detected . but 12 hou rs la ter displa cemen t of the hea rt to th e rig ht side combined with sudden ca rd iac failur e a ppeared . Emergency operation showed a right -sid ed rupture th e pericardium with complete hern ia tion of' thc heart into th e right pleural cavity and consequen t strang ulatio n by th e perica rdia\ m argin.
or
Traumatische Pe rikard ruptur mit bedrohl icher Herz ver-lagerung in die rech te Pleurahtihle Diese Fallbese hre ibung schildert die Diag nose und Th erapi e cines 19ja hr igen Patienten . der im Verla uf eines Verkeh rsun falls von einem Las twage n gege n c ine Mau er gedriickt w urde
In troduction
Herni ation of the heart following sta b wounds, as well as congenital pericardia! defects - especially involving the left ventr icular part of the pericardium - a re seldo m but nevertheless well known and described (I, 5). Isolated pericardial rupture with subse quent herniation of the heart into the right pleura. with no injury to the heart and no clinically relevant symptoms at a dmiss ion, is a rarely known occasion to be seen after blunt chest trauma (3) .
This manuscript describ es our experience in dia gnosis and treatm ent of a patient with traumatic herniati on of the beart into the right pleura through a per icardia I rupture ca used by a traffic accident. Case Report A 19-yea r-old male pa tient suffered a blunt chest trau ma after being rammed by a truck and pr essed aga inst a wa ll d ur ing a tra ffic accident. The pati ent was admitted a short while later to th e trau ma unit after having been intu bated by the attending med ical person nel d uring tra ns portation by helicopter. On a dmiss ion . no serious lifeth reatening inju ries could be detected , except two fra ctu red ribs a nd a righ t sided hem oth orax which was subseque ntly t reated by insertion of a ches t dr ain. Hadi ological and ca rdiologi cal diagnostic proced ures includ ing transoesopha gea l echo showe d no furth er signs of serious injury. CK-MB enzy me and electroca rdiogra m (61show ed no sig ns of cardiac contusion . The patient was tr an sferred to the intens ive care unit for fur th er recovery.
Thorae. cardiovasc. Surgeon 38 (1990 ) 379 - 380 © Georg Thieme Verlag Stuttgart New York
und ein stumpfes Thor ax-Tra um a er litte n hatte. Nac h der Splta lsaufna hmc kon ntcn mit Ausna hme cines rec htsseitigen l lam atoth ora x und Hippen fra ktu ren kei ne ern st ha f't en Vorletzungen dia gn ostiziert we rden . 12 Stunden spatcr tra ten klinische Zeiche n der ll erztam ponade a uf. und in der Thor ax-Ober sichtsaufna hme kon nte cine Verlageru ng des Horzschattons a uf die recht e Soite gosobcn worden . In der na chfolgen de n Notfallop era tion fa nd sich cine Huptu r des Perikardsackes an der re chte n Umschlagfalt e mit einer kompletten Verlagerung des Hcr zens in die rechte Pleu ra und Stra ngulat ion du rch die Perikard ra nde r . Das Herz konnte kc mplik ationsfrei re poniert und das Per ikard versch lossen we rden . Key words Blunt chest tr aum a - Per ica rdia! rupture - Ilernia tion of the heart
Tw elve hou rs after ad mission sudden signs cha ract er ist ic of card iac tam ponade a rose, includ ing a rising central ven ous pressur e and a low cardiac output. Radi ogra phic investigation showed a displacemen t of the hea rt to the right side ('-:ig. 1)a nd the hea rt beat was pa lpa ble on t he right side of the sternum. Eme rgenc y cardiac surgery was perfor med according to the usua l hosp ita l ro utine . Followin g ste rnotomy. careful ins pection 01' the mediastinu m was done : a retros ternal hematoma was found, a nd the perica rdium was ope ned by incisio n. Most strikingly the pericardial bag wa s found tota lly empty (Fig. 21 but with a righ tside d posterior rupt ure ofthe perica rd ium. The hea rt was found to be rotated and complete ly hern ia ted int o the righ t pleural ca vity a nd the margins of the perd icardi um we re ca usi ng a bri dle stricture of the pulmonary art ery as well as the caval veins. The heart was placed back into nor ma l pos ition in the perica rdia! bag and the peri card ial defect then close d by continuo us suture. The postoper a tive cours e was free of a ny kind of ca rdiac comp lications . Postoperative echo showed a normal left vent ricular function and no da mage caused to th e valve s.
Discussion
Peric ardial defects are a seldom congenital malform ation and may resu lt in herniati on of the heart which may ca use stra ngulation an d subsequent symptoms (7). Clinically. complete or partial pericardial defects are describ ed to be acco mpanied with retrosternal pain , syncopes, cardiac a rrhythmia. an d even sudden ca rdiac death (7). Means of diagno sis in such patient s are echoca rd iogra phy (9) and computer tomo graph y [l O), as well as jugular phlebograms (8) .
Received for Publi ca tion : J une 18. 1990
Downloaded by: University of British Columbia. Copyrighted material.
I
2
Thora c. card iov asc. Su rgeon 38 (19 90)
Fig. 1 Chestradiograph showi nga displacement ofthe heartto the rightside, following the sudden appearance of cardiac failure 12 hours after admission
R. Fasol , K. Louika . G. Noldqe , and V. Sch loss er
Fig.2a Intraoperativephotograph demonstratingthe empty pericardial bag witha right sided.posteriorruptu re ofthe pericardium.The heart is rotated and completelyherniated into the right pleural cavity
Pati ents with tra umatic cardiac injury or a blunt chest trauma wit h subse quent ca rd iac cont usion are normally admitted in a serious state whi ch obviousl y requires imm ediate treatme nt (2, 4). In contrast, th e diag nosis of isolated pericardial ruptu re following blunt trauma ma y be difficult, if all diagnostic pr ocedur es show no signs of serious injury on admission . In dealing with suc h patients, initial assessme nt of isolated per icardial rup ture may be tri cky: the clinical symptoms of the herniati on and st ra ngu lation of the heart ap peared in our patien t 12 hours after the eve nt. The real source of sudden cardiac failure could not be proven in our pa tient until surgical explora tion of the pericardium, over lookin g of this type of injury ma y have ea sily occurre d. This expe rience is a warning that the unusual complication of isolated pericardial ruptur e cause d by blunt che st trauma may have delayed results not signalled in initial exte ns ive diagnostic pro cedur es. References
.~
. .. ..... .. 0"
2
3 4
5 6
7 8
.'
:
.
.
".
'. )'
>: :'
,~ ., '
c>
':'. '
Fig.2b
RP: I
; . : .."
, RP , . : ~ .. , :' " . . . :.;' ':, ' . , ..: ~..
A mi ri, A .. Ch. Weber. V. Sc hlosse r. and T. H. Mein ertz: Coronary
LA:
Artery Disease in a Patient with a Congenital Pericard ial Defect. Thora c. Cardiovasc. Surgeon 37 (1989) 379-38 1 Bogers . A. 1. J. C . D. J. Zuieers, E. M. Vroom. and H. A. Huy sm an s: Cardiac S ublux atio n in Traumatic Rup tur e of Diaphragm and Pericardium. Thora c. Cardiovasc. S urgeo n 34 (1986) 132- 134 Cliffo rd. R. P.. and K. S. Gill: Trau mat ic ruptur e of the pericardium with dislocation of the heart. Injury 16 (1984) 123 Fasol, R.. P. Zilla. and S. Irvine: Thoracoa bdominal injuri es in combat casualties on the Cambodian border. Thorac . Cardiovasc. Surgeon 36 (1988) 33 Hermann. H.. A. E. Raizer. R. A . Chahine , and R. J. Luchi: Congenital absence of the pericardium. South . Med. J . 69 (1976) 1222 Kettun en. P.: Cardiac damage after blunt chest trauma. diagnosed using CK-M B enzyme and electrocardiogra m. Int. J . Cardiol. 6 (1984) 355 l.equ errier, A .. 1. Mi lon, et D. Milon : Les agenesies du pericarde gauche. Bull. Ass. Anat. 63 (1987) 479 Ma ts uhisa, M.. S. Beppu, and K. S himonura : Postur al effects in the jugular phlebogram in patients with complete absence of the left pericar dium. J . Cardiogr. 16 (1986) 699
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