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Yamashita T, Asai K, Ochiai H, Kanai T, Matsubayashi Y, Tanaka K, Hashimoto T. Connected simultaneous rupture of the diaphragm and pericardium via congenitally fused site due to blunt trauma. GENERAL THORACIC AND CARDIOVASCULAR SURGERY CASES 2023. [PMCID: PMC9891893 DOI: 10.1186/s44215-022-00018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background In severe blunt trauma, multiple organ injuries are often observed. Patients with a ruptured diaphragm and pericardium are referred to as having pericardio-diaphragmatic rupture. However, few studies have reported a narrowly defined case of connected rupture of the diaphragm and pericardium via their congenitally fused site along with an abdominal visceral herniation and cardiac luxation into the thoracic cavity. Case presentation A 78-year-old man presented to our hospital with left chest pain caused by a traffic accident. Contrast-enhanced computed tomography revealed a left diaphragmatic rupture and an intestinal herniation into the thoracic cavity. Surgical repair of the diaphragm was performed, and pericardial rupture was noted during surgery. It was considered that the laceration had spread via the congenitally fused site of the diaphragm and pericardium. The diaphragm was sutured, but the pericardium was left open because the laceration was large and the risk of cardiac incarceration was thought to be low. One year after the operation, no recurrence of diaphragmatic hernia was observed and any circulatory symptoms were not occurred. Conclusions In cases of diaphragmatic laceration extending to the fused site of the pericardium, connected pericardial rupture should also be considered. It would be challenging to detect without intraoperative findings, and it is desirable to observe both the thoracic and abdominal cavities.
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Affiliation(s)
- Takashi Yamashita
- grid.413553.50000 0004 1772 534XGeneral Thoracic Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Nakaku, Hamamatsu, Shizuoka 432-8580 Japan
| | - Katsuyuki Asai
- grid.413553.50000 0004 1772 534XGeneral Thoracic Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Nakaku, Hamamatsu, Shizuoka 432-8580 Japan
| | - Hideto Ochiai
- grid.413553.50000 0004 1772 534XGastroenterological Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Nakaku, Hamamatsu, Shizuoka 432-8580 Japan
| | - Toshikazu Kanai
- grid.413553.50000 0004 1772 534XGastroenterological Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Nakaku, Hamamatsu, Shizuoka 432-8580 Japan
| | - Yuta Matsubayashi
- grid.413553.50000 0004 1772 534XGeneral Thoracic Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Nakaku, Hamamatsu, Shizuoka 432-8580 Japan
| | - Keizo Tanaka
- grid.413553.50000 0004 1772 534XCardiovascular Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Nakaku, Hamamatsu, Shizuoka 432-8580 Japan
| | - Takashi Hashimoto
- grid.413553.50000 0004 1772 534XCardiovascular Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Nakaku, Hamamatsu, Shizuoka 432-8580 Japan
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Mashiko K, Matsumoto H, Yasumatsu H, Ueda T, Yamamoto M, Funaki Y, Toshimitsu Y. Emergent surgery for cardiac herniation coexisting with complex blunt cardiac injury: A case report. Trauma Case Rep 2021; 32:100464. [PMID: 33816745 PMCID: PMC8010855 DOI: 10.1016/j.tcr.2021.100464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/16/2022] Open
Abstract
A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V-V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.
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Affiliation(s)
- Kazuki Mashiko
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Hisashi Matsumoto
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Hiroshi Yasumatsu
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Taichiro Ueda
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Mariko Yamamoto
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Yutaka Funaki
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Yasuko Toshimitsu
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
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3
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Comprehensive review of pericardial diseases using different imaging modalities. Int J Cardiovasc Imaging 2020; 36:947-969. [DOI: 10.1007/s10554-020-01784-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/29/2020] [Indexed: 12/17/2022]
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Özalp T, Küpeli M, Sönmezoğlu Y, Çakmak A, Akgül S, Fazlioğlu M, Tokat C. Blunt Diaphragmatic Injuries: Pericardial Ruptures. Indian J Surg 2017; 79:212-218. [PMID: 28659674 DOI: 10.1007/s12262-016-1455-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 02/10/2016] [Indexed: 11/28/2022] Open
Abstract
Blunt traumatic diaphragmatic injuries (BTDIs) can be misdiagnosed. Careful evaluation of associated injuries in BTDI is important. In this study, we evaluated treatment options and difficulties in the diagnosis of patients with BTDI. We evaluated ten patients retrospectively with BTDI admitted to our departments, between January 2004 and 2015. Age, gender, trauma type, symptoms, radiological findings, diagnosis time, location and grade of the diaphragmatic injury, surgical type of repair, associated injuries and pericardial rupture, and morbidity and mortality rates were recorded. The mean age of the patients was 46.7 years, and all were males. Ninety percent of BTDI was left sided, and 10 % was on the right side. The diagnosis was confirmed with chest radiograph in 50 % and computed tomography in 70 %. Radiological examination revealed hemothorax in 80 %, the loss of diaphragmatic shadow in 60 %, and visceral organ herniation to the thorax in 60 %. Multiple organ injuries were present in 90 % of cases. Pericardial rupture seen in 30 % was remarkable. Early surgery was performed for eight patients and late surgery for two patients. There were six patients with grade 4 or 5 central diaphragmatic injuries (CDIs). Multiorgan injury was present in all patients developing acute CDI. Multiple organ injury is much higher in patients with severe acute blunt trauma with CDI. Pericardial rupture rate is high in cases with acute BTDI and CDI. Proper diagnosis and early surgical management reduce morbidity and mortality.
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Affiliation(s)
- Tevrat Özalp
- Department of Thoracic Surgery, Amasya University, Amasya, Turkey
| | - Mustafa Küpeli
- Department of Thoracic Surgery, Gaziosmanpaşa University, 60100 Tokat, Turkey
| | - Yaşar Sönmezoğlu
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | | | - Siraç Akgül
- Department of General Surgery, Amasya University, Amasya, Turkey
| | - Mithat Fazlioğlu
- Department of Thoracic Surgery, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Cevdet Tokat
- Department of General Surgery, Amasya University, Amasya, Turkey
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5
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Kim DW, Jeong IS, Na KJ, Song SY, Lee KS, Kang SK. Intraoperative Diagnosis of a Pericardial Injury Associated with Multiple Diaphragmatic Ruptures in a Patient with Abdominal Blunt Trauma. JOURNAL OF TRAUMA AND INJURY 2016. [DOI: 10.20408/jti.2016.29.4.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Do Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Kook Joo Na
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Sang Yun Song
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Kyo Seon Lee
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Seung Ku Kang
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
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Pericardio-diaphragmatic rupture following blunt abdominal trauma: Case report and review of literature. Int J Surg Case Rep 2015; 19:168-70. [PMID: 26773877 PMCID: PMC4756212 DOI: 10.1016/j.ijscr.2015.12.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/20/2015] [Indexed: 11/27/2022] Open
Abstract
Pericardio-diaphragmatic should be suspected in high-velocity blunt thoraco-abdominal trauma. Pericardial rupture can be managed in an open or laparoscopic approach.
Introduction Traumatic diaphragmatic rupture (TDR) occurs in 0–5% of patients with major blunt thoraco-abdominal trauma, in most of them on the left side, and an early correct diagnosis is made in less than half of the cases (Meyers and McCabe, 1993; Ball et al., 1982). Presentation of the case We report a case of a forty-eight years old man who had a pericardio-diaphragmatic rupture after a high-velocity blunt abdominal trauma that was diagnosed and treated successfully. Discussion Pericardio-diaphragmatic rupture (PDR) is an uncommon problem that poses a diagnostic challenge to surgeons. The incidence of PDR is between 0.2% and 3.3% of cases with TDR (Sharma, 1999 [3]). Conclusion PDR should be suspected in any patient with high velocity thoraco-abdominal trauma. Early diagnosis is essential and needs a high index of suspicion. Early Management is important in decreasing morbidity and mortality.
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7
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Co-existence of a rare dyspnea with pericardial diaphragmatic rupture and pericardial rupture: a case report. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 12:173-5. [PMID: 26336505 PMCID: PMC4550023 DOI: 10.5114/kitp.2015.52865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 04/02/2014] [Accepted: 06/23/2014] [Indexed: 11/17/2022]
Abstract
Pericardial-diaphragmatic rupture is a rare condition which occurs after blunt trauma and involves the herniation of abdominal organs into the pericardium. A 77-year-old female patient presenting with complaints of palpitation and difficulty in breathing was admitted to the emergency room. Left lateral thoracotomy revealed the herniation of abdominal organs into the thorax. A pericardial-diaphragmatic rupture and a pericardial rupture were found to co-exist. The diaphragm and the pericardium were repaired primarily. The case is presented here because herniation of abdominal organs into the pleural cavity through the pericardium is a rare condition.
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8
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Banfi C, Rousse N, Juthier F, Midulla M, Hysi I, Guerbaaï RA, Prat A, Ennezat PV, Vincentelli A. Successful repair despite late diagnosis of traumatic pericardial rupture with cardiac herniation. Int J Cardiol 2014; 177:e147-9. [PMID: 25294171 DOI: 10.1016/j.ijcard.2014.09.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/17/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Carlo Banfi
- Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, F-59000 Lille, France; Université Nord de France, IFR 114, EA 2693, F-59000 Lille, France.
| | - Natacha Rousse
- Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, F-59000 Lille, France; Université Nord de France, IFR 114, EA 2693, F-59000 Lille, France
| | - Francis Juthier
- Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, F-59000 Lille, France; Université Nord de France, IFR 114, EA 2693, F-59000 Lille, France
| | - Marco Midulla
- Department of Cardiovascular Radiology, Centre Hospitalier Regional et Universitaire de Lille, F-59000 Lille, France
| | - Ilir Hysi
- Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, F-59000 Lille, France
| | - Raphaëlle-Ashley Guerbaaï
- Department of Cardiology, Centre Hospitalier Regional et Universitaire de Grenoble, Grenoble, France
| | - Alain Prat
- Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, F-59000 Lille, France; Université Nord de France, IFR 114, EA 2693, F-59000 Lille, France
| | - Pierre-Vladimir Ennezat
- Department of Cardiology, Centre Hospitalier Regional et Universitaire de Grenoble, Grenoble, France; Université Nord de France, IFR 114, EA 2693, F-59000 Lille, France
| | - Andre Vincentelli
- Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, F-59000 Lille, France; Université Nord de France, IFR 114, EA 2693, F-59000 Lille, France
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9
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Gunn JM, Savola J, Isotalo K. Left-sided diaphragmatic and pericardial ruptures with subluxation of the heart after blunt trauma. Ann Thorac Surg 2012; 93:317-9. [PMID: 22186460 DOI: 10.1016/j.athoracsur.2011.05.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/26/2011] [Accepted: 05/13/2011] [Indexed: 11/19/2022]
Abstract
We present a rare case of individual but simultaneous rupture of the left pericardium and diaphragm in a patient with multiple blunt trauma. Skeletal trauma was repaired uneventfully with internal plate fixation. Diaphragmatic rupture was suspected and diagnosed 13 days from the initial trauma when the patient exhibited chest pain, dyspnea, and nausea. Intraoperatively, a pericardial rupture was discovered along with subluxation of the heart and repaired with a mesh.
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MESH Headings
- Cardiac Surgical Procedures/methods
- Diaphragm/injuries
- Follow-Up Studies
- Hernia, Diaphragmatic, Traumatic/diagnosis
- Hernia, Diaphragmatic, Traumatic/etiology
- Hernia, Diaphragmatic, Traumatic/surgery
- Herniorrhaphy/methods
- Humans
- Male
- Middle Aged
- Pericardium/injuries
- Rupture
- Thoracic Injuries/complications
- Thoracic Injuries/diagnosis
- Thoracic Injuries/surgery
- Tomography, X-Ray Computed
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/surgery
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Affiliation(s)
- Jarmo M Gunn
- Department of Cardiothoracic Surgery, Turku University Hospital, Turku, Finland.
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10
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Assing M, Dragicevic N, Hazelton TR, Nallamshetty L. Delayed levorotation of the heart in traumatic pericardial rupture. Emerg Radiol 2010; 18:257-61. [DOI: 10.1007/s10140-010-0923-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 11/22/2010] [Indexed: 11/25/2022]
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Kamiyoshihara M, Nagashima T, Ibe T, Takeyoshi I. Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma. Gen Thorac Cardiovasc Surg 2010; 58:291-4. [PMID: 20549460 DOI: 10.1007/s11748-009-0520-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Accepted: 07/17/2009] [Indexed: 11/25/2022]
Abstract
A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.
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MESH Headings
- Accidental Falls
- Fractures, Bone/etiology
- Heart Injuries/diagnostic imaging
- Heart Injuries/etiology
- Heart Injuries/surgery
- Hemopneumothorax/etiology
- Hernia, Diaphragmatic, Traumatic/diagnostic imaging
- Hernia, Diaphragmatic, Traumatic/etiology
- Hernia, Diaphragmatic, Traumatic/surgery
- Humans
- Male
- Middle Aged
- Pericardium/diagnostic imaging
- Pericardium/injuries
- Pericardium/surgery
- Suture Techniques
- Tomography, X-Ray Computed
- Treatment Outcome
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/etiology
- Wounds, Nonpenetrating/surgery
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Affiliation(s)
- Mitsuhiro Kamiyoshihara
- Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Gunma, Japan.
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12
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Abstract
Cardiac herniation as a result of traumatic pericardial rupture is a serious injury and a difficult diagnosis to make on radiographic studies. Even with the more advanced imaging modalities, this rare diagnosis remains challenging. In a high-energy traumatic setting, there are chest radiograph and multidetector computed tomography findings that are strongly suggestive of cardiac herniation. The imaging, along with greater awareness of this injury, may provide a more rapid diagnosis, thus potentially preventing the severe clinical deterioration often seen in these patients.
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13
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Kimura N, Kudo M, Takahashi T, Kokaji K, Yozu R. Aortic insufficiency and cardiac herniation associated with blunt chest trauma. Int J Cardiol 2008; 137:e35-6. [PMID: 18674832 DOI: 10.1016/j.ijcard.2008.05.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2008] [Accepted: 05/29/2008] [Indexed: 11/26/2022]
Abstract
Aortic insufficiency and cardiac herniation due to pericardial rupture after blunt chest trauma are rare complications and are usually associated with high mortality. We report on a patient with simultaneous aortic insufficiency and cardiac herniation. He was involved in a falling accident, but initially presented no symptoms associated with the heart. At a later stage, he developed dyspnea on effort and a final diagnosis was completed. He was successfully treated surgically.
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14
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Nanda S, Pamula J, Bhatt SP, Turki MA, Myers E, Dale T. Cardiac herniation and volvulus with acquired dextrocardia: echocardiographic diagnosis. Echocardiography 2008; 24:870-4. [PMID: 17767539 DOI: 10.1111/j.1540-8175.2007.00496.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We report an extremely rare cause of elevated jugular venous pulse where two esoteric causes for the same-cardiac volvulus and cardiac herniation have occurred together. Echocardiographic evidence for making the diagnosis of cardiac volvulus--subcostal long axis, subcostal short axis, and suprasternal views--have been presented. Awareness of this complication is necessary as immediate intervention is mandatory for a positive outcome.
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Affiliation(s)
- Sudip Nanda
- Department of Internal Medicine, St. Luke's Hospital, 801 Ostrum Street, Bethlehem, PA 18015, USA.
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15
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Affiliation(s)
- Adam Z Barkin
- Beth Israel Deaconess Medical Center, Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts 02215, USA
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