Herniation of the heart

Thoracic hernias: What the radiologist should know

Thoracic hernias encompass the protrusion of thoracic contents through the thorax or intra-abdominal tissue into the thorax. They can be classified as diaphragmatic hernias - either congenital or acquired; pulmonary hernias - involving tissue protrusion through cervical fascia or intercostal spaces; and mediastinal hernias - including cardiac, intrapericardial and hiatal hernias. Prompt identification and classification of thoracic hernias rely on diagnostic imaging, primarily through computed tomography and magnetic resonance, to identify associated complications. This article comprehensively reviews thoracic hernias and their key imaging features.

Traumatic pericardial rupture with secondary cardiac herniation in a dog

OBJECTIVE

To describe the unique finding and treatment of a dog with cardiac herniation due to traumatic pericardial rupture.

CASE SUMMARY

A 6.5-year-old entire male Yorkshire Terrier was presented for further management after being hit by a car. Despite suspected significant intrathoracic trauma at that time, the patient regained hemodynamic stability and had orthopedic surgery to correct a right iliac fracture. The patient was readmitted to the hospital 12 days following the initial visit due to considerable respiratory difficulty after accidentally being dropped several feet. Thoracic radiographs revealed an unusual severe mediastinal shift to the left with an atypical position of the cardiac silhouette against the left lateral thoracic wall. Due to the severe respiratory compromise of the patient and newly developed pneumothorax, an exploratory thoracotomy was recommended, where a complete rupture of the pericardium was identified, with secondary left-sided prolapse of the heart. Other more common intrathoracic injuries (ie, lung perforation, rib fractures) were also identified and partially repaired. The patient recovered successfully and was discharged 4 days postoperatively.

NEW OR UNIQUE INFORMATION PROVIDED

This is the first case report in the veterinary literature of traumatic pericardial rupture and cardiac herniation. According to human case descriptions, this is a rare and often fatal occurrence, which can be significantly challenging to diagnose preoperatively or antemortem. Emergency veterinary clinicians should be aware of this rare but important complication of blunt thoracic trauma. Surgical intervention may be necessary in cases with suspected or confirmed entrapment of great vessels or cardiac chambers, although these abnormalities were not present in this case.

Anesthetic management of thoracotomy for massive intrathoracic solitary fibrous tumor of the pleura: a case report

BACKGROUNDS

Solitary fibrous tumor of the pleura (SFTP) is a rare thoracic tumor and usually asymptomatic. Massive SFTP may affect adjacent organs and tissues including pulmonary vasculature, bronchus and heart. A thoracotomy for massive SFTP is necessary in severe case. Therefore, it is important for anesthesiologists to understand the condition of patients with massive SFTP and develop an appropriate anesthetic management strategy. A 76-year-old woman with massive SFTP presented to our clinical center and was evaluated as requiring thoracotomy. She received multidisciplinary cooperation treatment from the radiology, cardiac, thoracic surgery and anesthetic teams. The perioperative management of anesthesiologists played a crucial role in the great prognosis of this woman.

CONCLUSIONS

This case report demonstrates the importance of comprehensive and meticulous perioperative management and provides guidance to the multidisciplinary team on the potential risk and the rational treatment strategy of patients with massive SFTP during the perioperative period.

A rare case of survival after traumatic blunt ventricular rupture

A male in his 40s presented to the trauma center via air ambulance after colliding with a cement wall at highway speeds. Cross-sectional imaging revealed a right ventricular pseudoaneurysm, confirmed by echocardiography. He was taken emergently to the operating room where he was found to have a pericardial laceration, hemopericardium and a right ventricular rupture, which was primarily repaired. Postoperatively, the patient was transferred to intensive care and after 34 days in the hospital was ultimately discharged home.

Cardiac Outpouchings: Definitions, Differential Diagnosis, and Therapeutic Approach

Background and Aims

Cardiac outpouchings encounter a series of distinct congenital or acquired entities (i.e. aneurysms, pseudoaneurysms, diverticula, and herniations), whose knowledge is still poorly widespread in clinical practice. This review aims to provide a comprehensive overview focusing on definition, differential diagnosis, and prognostic outcomes of cardiac outpouchings, as well as further insights on therapeutic options, in order to assist physicians in the most appropriate decision-making.

Methods

The material reviewed was obtained by the following search engines: MEDLINE (PubMed), EMBASE, Google Scholar, and Clinical Trials databases, from January 1966 until March 2021. We searched for the following keywords (in title and/or abstract): (“cardiac” OR “heart”) AND (“outpouching” OR “outpouch” OR “aneurysm” OR “pseudoaneurysm” OR “false aneurysm” OR “diverticulum” OR “herniation”). Review articles, original articles, case series, and case reports with literature review were included in our search. Data from patients with congenital or acquired cardiac outpouchings, from prenatal to geriatric age range, were investigated.

Results

Out of the 378 papers initially retrieved, 165 duplicates and 84 records in languages other than English were removed. Among the 129 remaining articles, 76 were included in our research material, on the basis of the following inclusion criteria: (a) papers pertaining to the research topic; (b) peer-reviewed articles; (c) using standardized diagnostic criteria; and (d) reporting raw prevalence data. Location, morphologic features, wall motion abnormalities, and tissue characterization were found to have a significant impact in recognition and differential diagnosis of cardiac outpouchings as well as to play a significant role in defining their natural history and prognostic outcomes.

Conclusions

Careful recognition of cardiac outpouchings remains a diagnostic challenge in clinical practice. Due to a broad cluster of distinctive and heterogeneous entities, their knowledge and timely recognition play a pivotal role in order to provide the most appropriate clinical management and therapeutic approach.

A case report of blunt cardiac rupture

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Cardiac rupture is a full thickness laceration of the myocardium that occurs after blunt chest trauma.

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They are notoriously fatal, with only a handful of patients documented to have survived this injury.

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In cases where there is laceration of the pericardium, cardiac injury may not be obvious on initial assessment.

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A high degree of suspicion along with early recognition and prompt operative intervention can reduce mortality for these disastrous injuries.

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Despite its rarity, a differential diagnosis of cardiac rupture should be entertained in patients with low velocity blunt chest trauma who present with haemothorax.

Introduction

Cardiac rupture is a full thickness laceration of the myocardium that occurs after blunt chest trauma. They are notoriously fatal, with only a handful of patients documented to have survived. These injuries are not commonly associated with low energy chest trauma and may be overlooked as a differential in trauma cases if health care providers are not aware of their possibility. We now report the case of a patient who survived this injury. We believe this is the 16th reported survivor of blunt cardiac rupture.

Presentation of case

A 46-year-old construction worker was brought to the emergency department following blunt chest trauma. On arrival he was hypotensive and tachycardic. There was a transient response to intravenous fluid resuscitation. He was found to have a contusion to the left anterior chest wall and left haemothorax on imaging with normal mediastinum. Emergency left anterolateral thoracotomy revealed a pericardial and left ventricular laceration which was repaired. He was weaned off ventilatory support on day 4 post exploration and had an uneventful recovery.

Discussion

Survival after blunt cardiac rupture is extremely low. In the past 60 years, only 15 cases have been described where patients survived this injury. They are usually immediately fatal and are caused by high velocity injuries. Our case was interesting because, this injury was due to a low velocity injury resulting in ventricular laceration due to a displaced rib fracture. We believe this is the 16th reported survivor of blunt cardiac rupture.

Conclusion

It is important, therefore, for first responders to recognize that blunt cardiac rupture can also result from seemingly innocuous, low velocity injuries so that the diagnosis can at least be entertained early. Survival depends on early diagnosis and prompt thoracotomy.

Cardiac Injuries: A Review of Multidetector Computed Tomography Findings

Trauma is the leading cause of death in United States in the younger population. Cardiac trauma is common following blunt chest injuries and is associated with high morbidity and mortality. This study discusses various multidetector computed tomography (MDCT) findings of cardiac trauma. Cardiac injuries are broadly categorized into the most commonly occurring blunt cardiac injury and the less commonly occurring penetrating injury. Signs and symptoms of cardiac injury can be masked by the associated injuries. Each imaging modality including chest radiographs, echocardiography, magnetic resonance imaging and MDCT has role in evaluating these patients. However, MDCT is noninvasive; universally available and has a high spatial, contrast, and temporal resolution. It is a one stop shop to diagnose and evaluate complications of cardiac injury. MDCT is an imaging modality of choice to evaluate patients with cardiac injuries especially the injuries capable of causing hemodynamic instability.

Stab wound of the heart with unusual sequelae

A 31-year-old woman was admitted to the emergency department with a stab wound to the heart. She was initially stable but rapidly developed hypotension. While the operating room and staff were in preparation, she underwent pericardiocentesis. She was then rushed to the operating room by the general surgical trauma team, who performed a bilateral anterior thoracotomy to control the bleeding. In the recovery room, the patient was still hypotensive, so cardiothoracic surgery was consulted. An echocardiogram revealed severe hypokinesis of both ventricles. The cardiothoracic surgeons returned her to the operating room and discovered that the anterior pericardium had been completely removed by the trauma team. This had caused the posterior pericardium to form a "bowstring" that almost totally obstructed pulmonary venous return and restricted right ventricular outflow of blood, inducing right-sided heart failure. This pericardial string also strangulated the left atrium posteriorly, forming 2 compartments. We repositioned the patient's heart and implanted ventricular assist devices bilaterally to provide temporary circulatory support. The patient made a good recovery. We suggest that bilateral assist device placement can be beneficial in the recovery of a stunned but otherwise normal heart.

Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports

BACKGROUND

Blunt Traumatic Pericardial Rupture (BTPR) with resulting cardiac herniation following chest trauma is an unusual and often fatal condition. Although there has been a multitude of case reports of this condition in past literature, the recurring theme is that of a missed injury. Its occurrence in severe blunt trauma is in the order of 0.4%. It is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity and associated polytrauma. Of the patients who survive to hospital attendance, the mortality rate is in the order of 57-64%.

METHODS

We present two survivors of BTPR and cardiac herniation, one with a delayed penetrating cardiac injury secondary to rib fractures. With these two cases and literature review, we hope to provide a greater awareness of this injury

CONCLUSION

BTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with:Cardiovascular instability with no obvious cause. Prominent or displaced cardiac silhouette and asymmetrical large volume pneumopericardium. Potentially, with increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac Herniation could even be considered the 5th H of reversible causes of blunt traumatic PEA arrest.

Left ventricular hernia in a pediatric transplant recipient: case report and review of the literature

Cardiac hernias are rare occurrences resulting from congenital pericardial defects, trauma, or postsurgical changes. Difficult to diagnose, they can lead to significant morbidity and mortality. The first reported case of left ventricular herniation in a pediatric cardiac transplant recipient is presented, and the literature concerning diagnosis and management is reviewed. Clinicians must have a high index of suspicion to diagnose this rare and potentially lethal defect.

The Cardiac Pendulum: Blunt Rupture of the Pericardium with Strangulation of the Heart

BACKGROUND

Blunt injury of the pericardium with strangulation of the heart is a rare clinical injury.

METHODS

We conducted a review of clinical records and performed prospective collection of forensic data from a large urban medical examiner's office.

RESULTS

Ten cases of blunt injury to the pericardium were identified. All were secondary to blunt trauma. Nine of the 10 cases had associated chest wall injuries and 5 of the 10 cases had cardiac strangulation.

CONCLUSION

Pericardial lacerations are common findings at autopsy. Clinically, those that survive to the hospital have a confusing presentation. They are often diagnosed during emergent thoracotomy for hemodynamic instability. Hemodynamic deterioration associated with change in patient position may be a clue to cardiac strangulation.

[Cardiac hernia after intrapericardial pneumonectomy]

Cardiac herniation secondary to intrapericardial pneumonectomy is a rare complication, although its real incidence has surely been underestimated. We describe a patient with left cardiac herniation presenting after intrapericardial pulmonectomy for primary lung cancer. The signs were severe hemodynamic shock requiring additional surgery involving a wide opening in the pericardium. The outcome after surgery was fully satisfactory.

Cardiac herniation producing tamponade: the critical role of early diagnosis

BACKGROUND

Rupture of the pleuropericardium (PP) occurs rarely, with most patients dying of associated injuries before arriving at the hospital. Among patients who initially survive, the diagnosis is often delayed until cardiogenic shock secondary to cardiac herniation is evident.

METHODS

The records of 10 patients with PP lacerations and cardiac herniations were reviewed.

RESULTS

All but one patient had a normal chest x-ray (CXR) film on admission. After the patients became symptomatic, seven of nine had abnormal findings on CXR film demonstrating herniation of the heart into the left hemithorax. The other two patients underwent surgery without a repeat CXR film. Except for one who was taken directly to the operating room, all patients had been previously stabilized before developing cardiogenic shock, on average 9 hours after admission. Operative therapy was closure of the pericardium for five patients and completion pericardiotomy for the others. All survivors developed significant complications, and four of them died.

CONCLUSIONS

The diagnosis of PP rupture should be considered for patients with multiple trauma who develop sudden and unexpected cardiogenic shock after their initial condition has been stabilized. A repeat CXR film is diagnostic in most cases and should be used as the most efficient and expeditious route to making the diagnosis.

Traumatic tricuspid valve rupture with luxation of the heart

Three patients are described with the combination of a luxation of the heart through a pericardial tear and traumatic rupture of the papillary muscle of the tricuspid valve. In only 1 patient was the dislocation of the heart suspected preoperatively. In all 3 patients operative treatment was performed with considerable delay after the accident; nevertheless, all 3 patients survived. In all cases treatment consisted of repositioning of the heart, closure of the pericardium, and valvular repair of the tricuspid valve.

Cardiac torsion after lobectomy with partial pericardectomy

Cardiac herniation and torsion after intrapericardial pneumonectomy without closure of the pericardium is widely recognized. However, such a complication occurring after lobectomy has been rarely discussed in the literature. We describe a case of cardiac torsion of late onset that developed in a woman who had undergone left upper lobectomy as part of a resection for a malignant thymoma.

MR diagnosis of herniation of the left ventricle through a pericardial window

The diagnosis of herniation of the left ventricle through a pericardial window was made using MRI. This is a rare type of herniation because it presented 6 years after a pericardial window was made for pericarditis. Herniation of the heart through congenital, traumatic and post surgical pericardial defects are discussed.

Modification of the technique of radical intrapericardial pneumonectomy

Since radical intrapericardial pneumonectomy was introduced by Allison in 1945, complications of several serious types have been reported secondary to this technique. The authors have seen fatal cardiac herniation, as well as severe paradoxical respiration after sacrifice of the phrenic nerve. Simple technical steps can eliminate these dangers, and after introduction of the required changes we have not seen the former complications. The authors' techniques are described and a small series of animal experiments supporting their use is presented.

Pleural flap closure of pericardial defects following intrapericardial pneumonectomy

Persistent pericardial defects following intrapericardial pneumonectomy are, historically, the major cause of iatrogenic cardiac herniation. This complication is uniformly fatal when unrecognized and untreated and has been associated with a 43% mortality even with surgical correction. Suture approximation of all small defects is recommended, and a technique for routine pleural flap closure of moderate to large-sized defects is described.

Cardiac herniation following intrapericardial pneumonectomy

Deiraniya, A. K. (1974).Thorax, 29, 545-552. Cardiac herniation following intrapericardial pneumonectomy. Cardiac herniation is a rare and catastrophic complication of intrapericardial pneumonectomy. Untreated it is invariably fatal. This paper reports three cases of cardiac herniation following intrapericardial pneumonectomy. In two cases massive haemorrhage complicated the cardiac herniation. All three cases were re-explored with two immediate survivals. The diagnosis, aetiology, haemodynamic effects, and management of this complication are discussed, and previously reported cases are reviewed.