Cardiac herniation following intrapericardial pneumonectomy

Delayed cardiac herniation after left pneumonectomy

Cardiac herniation is a rare potentially life-threatening complication that can occur after pneumonectomy, involving displacement of the heart through a pericardial defect, which can lead to hemodynamic instability, impaired cardiac function, and in severe cases, death. We describe a case of delayed cardiac herniation 1-month post left pneumonectomy for pulmonary leiomyosarcoma.

Recognition and Management of Acute and Late Complications of Pneumonectomy: Clinical Cases and Treatment

Several important complications of pneumonectomy are discussed in a case-based format. Topics include chylothorax, cardiac herniation, postpneumonectomy syndrome, postpneumonectomy pulmonary edema, bronchopleural fistula, and empyema.

Cardiac herniation presenting as superior vena cava obstruction syndrome after intrapericardial pnemonectomy for locally advanced lung cancer---case report

Introduction

Cardiac herniation is a rare complication after pulmonary surgery, and there are only a few reports about it. We now report a case of cardiac herniation presenting as superior vena cava obstruction after pneumonectomy.

Case presentation

A-52-years old woman diagnosed right pulmonary squamous cell carcinoma was carried out right pneumonectomy, the pulmonary artery and right superior pulmonary vein were dissected and ligated intrapericardial. The patient developed tachycardia arrhythmias, hypotension, followed by loss of consciousness at about 18 h after operation. After resuscitation, the patient was conscious but developed cyanosis of the superior vena cava drainage area, uropenia, and hypotension (80/30 mmHg). Bedside-echocardiography showed that the SVC was obstructed due to thrombus formation. Chest radiography a shift of the heart into right hemithorax. Rethoracotomy was performed and the herniated heart was replaced into the pericardium, and the pericardium was repaired with Gore Tex patch. The patient recovered smoothly after the second surgery.

Conclusion

Cardiac herniation is a rare and fatally complication after thoracic surgery, and the prompt recognition with timely intervention is life-saving. Cardiac herniation is a rare but fatal complication of pneumonectomy. The increasing frequency of surgical resection for locally advanced thoracic carcinoma has led to a renewed emphasis regarding early diagnosis and treatment for cardiac herniation. Here we discuss a case of cardiac herniation presented with acute superior vena cava obstruction syndrome and hemodynamic instability after intrapericradial right pneumonectomy.

Case report: cardiac herniation following robotic-assisted thymectomy

BACKGROUND

The first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal surgical complication may occur following any operation in which a pericardial incision or resection is performed. The majority of literature on cardiac herniation involves case reports after intrapericardial pneumonectomy. Currently, there are no reports of cardiac herniation after thymectomy with pericardial resection.

CASE PRESENTATION

A 44-year-old Asian female with symptomatic myasthenia gravis was referred for thymectomy. Originally thought to have Bell's Palsy, her symptoms began with right eyelid drooping and facial weakness. Over time, she developed difficulty holding her head up, upper extremity weakness, difficulty chewing and dysarthria. These symptoms worsened with activity. She was found to have positive acetylcholine receptor binding antibody on her myasthenia gravis panel. A preoperative CT scan demonstrated a 3.5 cm × 2 cm anterior mediastinal mass along the right heart border and phrenic nerve. A complete thymectomy, via right-sided robotic-assisted approach was performed en bloc with a portion of the right phrenic nerve and a 4 cm × 4 cm portion of pericardium overlying the right atrium and superior right ventricle. Upon undocking of the robot and closure of the port sites, the patient became acutely hypotensive (lowest recorded blood pressure 43/31 mmHg). The camera was reinserted and demonstrated partial cardiac herniation through the anterior pericardial defect toward the right chest. An emergent midline sternotomy was performed and the heart was manually reduced. The patient's hemodynamics stabilized. A vented Gore-Tex 6 cm × 6 cm patch was sewn along the pericardial edges with interrupted 4-0 prolene to close the pericardial defect.

CONCLUSION

This potentially fatal complication, although rare, should always be considered whenever there is hemodynamic instability entry or resection of the pericardium during surgery. We now routinely sew in a pericardial patch using our robotic surgical system for any defect over 3 cm × 3 cm that extends from the mid- to inferior portions of the heart.

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.

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

Cardiac herniation is a complication that occurs after intrapericardial pneumonectomy. It is life-threatening unless promptly diagnosed and surgery performed. We report a case of cardiac herniation after right intrapericardial pneumonectomy following radiotherapy for lung cancer. The patient developed cardiac herniation with sudden hypotension following a switch to the spine position. An immediate switch to the lateral decubitus position improved the cardiocirculatory dynamics, and surgical patch closure was performed. The circulation dynamics was unstable for several hours after surgery with elevated enzyme levels, which improved 2 days later. Immediate thoracotomy before irreversible myocardial damage resulted in a successful outcome. The risk of cardiac herniation should always be considered after intrapericardial pneumonectomy.

Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma

Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. "Extended P/D" is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term "radical" was replaced by "extended" to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

A case of cardiac herniation after extrapleural pneumonectomy for malignant thymoma

A 44-year-old man underwent radical thymectomy for malignant thymoma 5 years ago. He subsequently underwent right extrapleural pneumonectomy because a right pleural metastatic lesion had developed. The operation was completed uneventfully. Immediately after arrival at the intensive care unit, the patient appeared restless and in pain. His heart rate increased to 140 bpm and then abruptly decreased to 20-30 bpm concomitant with profound systolic hypotension of 30-40 mmHg. Chest X-ray showed that the heart was shifted into the right thorax. Emergent re-thoracotomy was performed and the heart was found to be malrotated and herniated from an upper defect of the pericardial patch in the right thoracic cavity. The heart was returned to the pericardium and the defect was covered with a pericardial patch. The blood pressure and heart rate became stable. He was transferred to the surgical ward from the intensive care unit on the first postoperative day. The rest of the course was uneventful and the patient was discharged on the seventh postoperative day. The incidence of cardiac herniation after extrapleural pneumonectomy following chemotherapy for malignant pleural mesothelioma has been reported to be around 3%. The risk of cardiac herniation should always be considered, especially after extrapleural pneumonectomy.

Cardiovascular Complications After Lung Surgery

Cardiovascular complications following thoracic surgery remain a challenge to the physician, the hospital, and the health care system. These events add significantly to morbidity, mortality, and the cost of care of the general thoracic surgery patient. A proactive approach to identify patients at high risk for such complications is needed. In this manner, one may enhance prevention and treatment if problems occur. A thoughtful and complete preoperative risk assessment can identify patients who have potential contributing comorbidities, leading to a reduced incidence of postoperative events. Standardization of preoperative, intraoperative, and postoperative care can reduce postoperative events. Implementation of guidelines and pathways that are evidence based can lead to enhanced patient care, better patient and staff satisfaction, and improved outcomes from the operation. Although postoperative cardiac events cannot be completely eliminated from the thoracic surgery population, the prevention, treatment, and follow-up strategies outlined herein can attenuate these significant morbid and mortal events.

Cardiac herniation following pneumonectomy--an old complication revisited

Cardiac herniation is a recognised complication of pneumonectomy when a pericardial defect has been made during resection. This complication is very rare and, with the increasing preference for more limited resections, is even less frequently encountered now than it was several decades ago. Uncorrected cardiac herniation is usually lethal, with a high incidence of morbidity and mortality even after correction. We present a case of left-sided cardiac herniation following intrapericardial pneumonectomy to illustrate the difficulty of making this rare diagnosis. Aetiology, pathophysiology, clinical picture and diagnosis of cardiac herniation are reviewed. We also describe the treatment and prevention of this serious complication. Cardiac herniation should be considered in any patient with acute deterioration after pneumonectomy.

Sudden cardiac herniation 6 months after right pneumonectomy

Cardiac herniation is a rare complication of intrapericardial pneumonectomy and has a high mortality. The condition has been reported only within 24 hours after surgery. In this report, a case is described in which a total cardiac herniation took place 6 months after right intrapericardial pneumonectomy. The patient presented with an acute vena cava superior syndrome and underwent thoracotomy to reposition the heart into the pericardial sac and to close the pericardium with a patch.

Cardiac dislocation after extended pneumonectomy with pericardioplasty

Two cases of cardiac dislocation occurred after intrapericardial right pneumonectomy with extended pericardiectomy and radical nodal dissection in spite of proper reconstruction with a pericardial fat flap in one case and with a Gore-tex prosthesis in the other. In the case of major pericardial excision resulting in extensive mobilisation of the SVC a complete reconstruction of pericardium and mediastinal pleura is recommended in order to prevent cardiac dislocation.

Acute cardiac herniation after radical pleuropneumonectomy

Acute cardiac herniation after radical pneumonectomy is extremely rare and is associated with an immediate mortality greater than 50%. We report a patient in whom cardiac herniation produced no signs or symptoms. The heart was returned to its correct position and the pericardial defect was repaired.

[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.

Pericardial repair after extensive resection: another use for the pedicled diaphragmatic flap

BACKGROUND

Extended resection for pulmonary malignancy frequently leaves a large pericardial defect, sometimes associated with resection of the phrenic nerve. On the left the defect does not require repair; as long as the defect is sufficiently large to avoid constriction, the heart can herniate freely. On the right such herniation is associated with venous inflow occlusion and death. The pedicled diaphragmatic flap has been used in other situations in thoracic surgery. We have modified this to allow closure of the pericardial defect and concurrent plication of the denervated diaphragm. It may also be used to cover the bronchial stump or a bronchial anastomosis.

METHODS

The flap has been used in 13 patients over an 11-year period.

RESULTS

Secure closure of the pericardial defect has been achieved in all patients with satisfactory plication of the diaphragm. Reoperation for bleeding was necessary in 3 patients, but in only 1 was the diaphragm shown to be the site of bleeding. Patients otherwise made an uneventful recovery.

CONCLUSIONS

A large pedicled flap of redundant diaphragm provides secure closure for large pericardial defects after extended right pneumonectomy.

Delayed myocardial laceration after intrapericardial pneumonectomy

Curative resection for large central bronchogenic tumors may require radical or intrapericardial pneumonectomy. Myocardial herniation through the pericardial defect is a rare early postoperative complication. Prevention of cardiac herniation and subsequent hemodynamic compromise is always necessary after intrapericardial pneumonectomy.

Cardiac herniation after pneumonectomy

Cardiac herniation is a rare, lethal complication of intrapericardial pneumonectomy demanding urgent treatment. It usually occurs within the first 24 h postoperatively. We present a patient with late cardiac herniation, 28 h postoperatively, where the electrocardiographic changes were evident several hours before the clinical picture became clear. After the diagnosis was made, the patient was treated surgically and survived.

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.

Right ventricular outflow obstruction secondary to right-sided tamponade following myocardial trauma

A case of isolated tamponade of the right side of the heart, seen as an abrupt change in the cardiac silhouette and as right ventricular outflow obstruction following myocardial trauma, is presented, along with a review of the English-language literature on delayed postoperative tamponade and loculated pericardial effusion. The importance of a low, fixed cardiac output and nonspecific physical findings in suggesting the clinical diagnosis is emphasized. The absence of many of the classic signs and symptoms of pericardial tamponade is noted, as is the possibility of unusual changes in the appearance or function of the heart in the presence of a loculated effusion. Finally, the differential diagnosis and the results of a variety of diagnostic techniques are discussed.

Heterologous pericardium for the closure of pericardial defects

Patches of glutaraldehyde-preserved porcine pericardium were transplanted orthotopically into 20 dogs to see if they might make a satisfactory pericardial substitute. Two dogs had mediastinal infections and were excluded from this study. All animals were reoperated on at regular intervals between 15 and 300 days. In 15 dogs there were no adhesions between the porcine pericardium and the host's epicardium. Histological study showed healing between both pericardiums and no degenerative changes in transplanted pericardium. Glutaraldehyde porcine pericardium has been utilized in 8 patients to close the pericardial cavity. There have been no problems related to the pericardial grafts after a maximum follow-up of 9 months.

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.

Complications of pulmonary resection

The following complications of pulmonary resection are discussed with reference to their frequency of occurrence, etiology, diagnosis, and treatment: pulmonary insufficiency, arrhythmias, residual intrapleural air spaces, prolonged air leaks, postpneumonectomy empyema, bronchopleural fistula, cardiac herniation, lobar gangrene, esophagopleural fistula, pulmonary embolism, and tumor embolism.