Cardiac displacement after lobectomy in a patient with a congenital complete left-sided pericardial defect

A Case of Incidentally Discovered Congenital Complete Pericardial Defect during Lobectomy for Lung Cancer: A Case Report and Literature Review

An 82-year-old male patient underwent a left upper lobectomy with anterolateral thoracotomy for lung cancer. Although a complete left-pericardial defect was observed during surgery, the pericardial repair was not performed because the left lower lobe remained and the heart was considered stable. Postoperative pathological examination revealed primary synchronous double-lung squamous-cell carcinoma (pathological stage pT2a(2)N0M0 stage IB). He was discharged without complications on postoperative day 8. Leftward displacement of the heart and left diaphragmatic elevation, suspected of phrenic-nerve paralysis, were found in the chest X-ray after discharge. However, the patient's overall condition remained unaffected at the 5-month postoperative follow-up. To assess the need for pericardial repair, we compared cases of complete pericardial defects observed during lobectomy or pneumonectomy reported in the literature. Only one of 12 cases occurred postoperative death despite pericardial repair, and that case combined pectus excavatum and pericardial defects. Our assessment indicated that pericardial repair might not be necessary, excluding complex cases.

Congenital partial pericardial defect discovered incidentally during surgery for lung cancer: a case report and literature review

BACKGROUND

Congenital pericardial defects are rare congenital anomalies, often asymptomatic and incidentally detected during thoracic surgery.

CASE PRESENTATION

A 74-year-old man with primary lung cancer (cT1cN0M0, Stage IA3) underwent thoracoscopic radical lobectomy. At the time of thoracotomy, a pericardial defect was found on the ventral side of the hilar region, and the left atrial appendage was exposed. Due to concern that contact between the bronchial stump and the left atrial appendage may lead to postoperative bleeding and heart hernia, the pericardial defect was closed with an expanded polytetrafluoroethylene GoreTex® membrane. Preoperative computed tomography was reanalyzed with a 1 mm slice, congenital pericardial defect was detected as the pericardium had penetrated under the left atrial appendage.

CONCLUSIONS

In congenital partial pericardial defect, contact between the left atrial appendage and bronchial stump, due to movement of the lung or heart, increases the risk of bleeding after lung resection. Therefore, closure of the defect should be considered. Although it is difficult to diagnose congenital partial pericardial defect preoperatively, computed tomography taken with a slice thickness of 1 mm is useful for diagnosis.

Lobectomy for Lung Cancer With Congenital Pericardial Defect

A congenital complete pericardial defect is a rare and often asymptomatic condition that may be diagnosed intraoperatively. While performing lung lobectomy in patients with this condition, surgeons must exercise more caution than with standard lobectomies. Additional points of consideration include the use of surgical instruments to ensure a clear operative field, vascular treatment for pulmonary veins, confirmation of the phrenic nerve location, and determination of the need to repair the pericardial defect. This report describes a rare case of a complete left pericardial defect that was detected in a man with lung cancer during left upper lobectomy.

Giant bronchogenic cyst with pericardial defect: a case report & literature review in Japan

Congenital pericardial defects are a rare anomaly, found during autopsy and cardiothoracic surgery. We describe a case of a 69-year-old female, with a right-sided congenital pericardial defect associated with a giant bronchogenic cyst (BC) found during surgery. The cyst was resected and the patient developed arrhythmia following surgery. A review of the literature in Japan was performed, focusing on congenital anomalies associated with pericardial defects and its pathogenesis. We paid particular attention to complications following thoracic surgery in patients with pericardial defects and indications of pericardial reconstruction in such patients.

Congenital defects of the pericardium: a review

Pericardial defects are a rare disorder that can be characterized as acquired or congenital. Congenital defects can be further characterized by location and size of the defect, e.g. left- or right-sided and partial or complete absence of the pericardium. While physical examination and electrocardiogram are not diagnostic, chest radiographs and echocardiography have findings that should alert the clinician to the absence of the pericardium as a possible diagnosis. Despite its limitations with visualizing the normal pericardium in areas of minimal adipose, cardiac magnetic resonance is currently the gold standard for diagnosing the congenital absence of the pericardium. Patients have a similar life expectancy to those without pericardial defects; however in certain cases, herniation and strangulation of cardiac chambers can be life threatening and lead to sudden cardiac death. Treatment is tailored to the patient's symptoms, presentation, and the size and location of the defect.

Bronchogenic cyst associated with congenital absence of the pericardium

We report a rare case of bronchogenic cyst associated with congenital complete absence of the pericardium. A 17-year-old male was admitted to the hospital for surgical resection of a growing cystic lesion located in the middle mediastinum. The patient was asymptomatic and no significant findings were found on physical examination. Resection of the mediastinal cyst was performed by video-assisted thoracoscopic surgery. The complete absence of the pericardium was immediately observed along with a cystic tumor arising from the mediastinum. After the resection of the cyst, no additional procedure to reconstruct the absence of the left pericardium was performed. Pathological diagnosis was a bronchogenic cyst. Congenital absence of the pericardium may be associated with the bronchogenic cyst and complete absence of the pericardium requires no additional surgical reconstruction, if remaining space in the pleural cavity is small enough to avoid cardiac disposition after surgical resection of the cyst.

Complete left-sided pericardial defect in a lung cancer patient undergoing pneumonectomy without closure of the defect

A 61-year-old asymptomatic man underwent a left pneumonectomy for Stage IIIA lung cancer. At thoracotomy, the pericardium was found to be completely absent; however, we did not close the defect. Although the heart was rotated toward the left pleural cavity in the postoperative chest computed tomography (CT), the postoperative course was uneventful, and the patient has remained asymptomatic for 7 months, since the resection. We reviewed the preoperative chest CT, which showed the heart extending unusually to the left, but the pericardial defect was not evident. Complete pericardial defects usually do not endanger the lives of patients, and if the patient is asymptomatic, surgical repair of the defect may be unnecessary even during a left pneumonectomy.