Case report of cardiac herniation after sleeve pneumonectomy with superior vena cava reconstruction

Cardiac herniation identified without any symptoms following extrapleural pneumonectomy: a case report

BACKGROUND

Cardiac herniation, especially right-sided herniation, is a fatal complication which causes sudden hypotension due to obstruction of the vena cava. Here, we describe a case of cardiac herniation identified without any symptoms after right extrapleural pneumonectomy performed for diffuse pleural mesothelioma.

CASE PRESENTATION

A 72-year-old man with diffuse pleural mesothelioma underwent a right extrapleural pneumonectomy after chemotherapy. The tumor had widely invaded the pericardium, necessitating pericardial resection. The pericardial defect was approximately 10 × 6 cm and was reconstructed with a 0.1-mm polytetrafluoroethylene sheet. Routine chest radiographs taken just after the operation were normal. A chest radiograph on postoperative day one revealed cardiac herniation but he remained hemodynamically stable. An urgent re-thoracotomy was performed for pericardial reconstruction. Severe hypotension occurred immediately before the operation, but was improved upon placing the patient in the left lateral decubitus position. Postoperatively, he developed postoperative complications including chylothorax and empyema, and was discharged 118 days after surgery.

CONCLUSIONS

Cardiac herniation can occur without any symptoms following right pneumonectomy with pericardiectomy. Urgent reoperation is warranted due to the high risk of impending shock, even in hemodynamically stable patients.

A case series of VATS intrapericardial pneumonectomy: a bi-centric experience

BACKGROUND

Intrapericardial pneumonectomy is a complex procedure indicated for large lung tumors where safe dissection of major vascular structures outside the pericardium is unfeasible or when the pericardium itself is invaded. Traditionally managed via open thoracotomy, recent advancements in VATS techniques now allow for intrapericardial pneumonectomy even in cases with extensive tumors or locally advanced disease. In this article, we detail the clinical outcomes and surgical considerations of six patients with non-small cell lung cancer who underwent VATS intrapericardial pneumonectomy. In this article, we detail the clinical outcomes and surgical considerations of six patients with non-small cell lung cancer who underwent VATS intrapericardial pneumonectomy.

CASE PRESENTATION

This study analyzed data from 24 patients who underwent VATS pneumonectomy for non-small cell lung cancer at two thoracic surgery centers in Turkey between January 2015 and March 2024. Among them, 6 patients underwent intrapericardial pneumonectomy; 5 had left pneumonectomy, and 1 had right pneumonectomy. All patients were male, with a mean age of 72.8 years, and a mean tumor size of 6.2 cm. Pericardial invasion was observed in 5 patients. Postoperative complications included respiratory failure and septic shock in one patient, leading to death. Long-term follow-up showed one additional death due to cancer progression; four patients are alive and under routine follow-up.

CONCLUSIONS

VATS intrapericardial pneumonectomy offers a viable alternative to traditional open surgery for patients with large or locally advanced non-small cell lung cancer, providing enhanced visualization, reduced postoperative pain, and faster recovery. Our multi-center experience with six patients demonstrates the procedure's feasibility and safety, even in challenging cases with pericardial invasion. Despite the complexity of the surgery, the use of advanced VATS techniques and careful intraoperative assessments can lead to successful outcomes. However, given the associated risks, especially with postoperative complications, further studies with larger cohorts are needed to validate these findings and refine surgical techniques.

A new technique for closure of pericardial defects: pericardial rug weave

BACKGROUND

Pericardial defect that occurs after intrapericardial pneumonectomy can cause many fatal complications, and closing the defect with mesh is a widely used surgical method to prevent these complications.

METHODS

Data of patients who underwent intrapericardial pneumonectomy and pericardial resection in our clinic between October 2010 and June 2022 were retrospectively reviewed. Patients were divided into two groups, those who had prolene mesh used to close the pericardial defect and those who underwent the "Rug Weave" technique we proposed as an alternative, and the results were compared.

RESULTS

The study included 23 patients, one of whom was female. All patients underwent surgery due to malignancy. The vast majority of the patients had a diagnosis of squamous cell lung carcinoma (86.9%). Atrium was added to three patients and rib resection was added to one patient during intrapericardial pneumonectomy and pericardial resection. There was no significant difference between the two groups in terms of average age, gender, and length of hospital stay. There was no significant difference between the two groups in terms of complications, including atrial fibrillation, which is commonly seen in these patients (p = 0.795). The Rug Weave group had an average defect width of 23.96 cm2 and was found to be advantageous in terms of overall survival compared to the mesh group (p = 0.017).

CONCLUSIONS

The "Rug Weave" technique we proposed for closing pericardial defects after pneumonectomy can be used as a cheaper method safely and effectively that reduces complications as much as the traditional method of using mesh.

Cardiac herniation after extrapleural pneumonectomy

Cardiac herniation is a fatal complication in patients undergoing pneumonectomy with pericardial resection. A 53-year-old man underwent right-sided extrapleural pneumonectomy for malignant pleural mesothelioma. He underwent right-sided pericardial resection and reconstruction with an expanded polytetrafluoroethylene sheet. Routine chest radiography performed 18 h postoperatively revealed cardiac herniation into the right-sided thoracic cavity. The patient was immediately transferred to the operating room, and the defect was repaired. He died of tumor progression. However, cardiac herniation did not recur over 2 years postoperatively.