Blunt traumatic rupture of the pericardium with cardiac herniation

Emergent surgery for cardiac herniation coexisting with complex blunt cardiac injury: A case report

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.

Blunt Thoracic Trauma-Induced Mitral Papillary Muscle Avulsion with Pericardial Rupture and Cardiac Herniation: Difficult and Delayed Diagnoses

Blunt thoracic trauma (BTT) and the resultant isolated mitral papillary muscle avulsion, pericardial rupture, and cardiac herniation injuries are each rarely diagnosed clinical entities. We describe the first case of combined pericardial tear with cardiac herniation and ruptured mitral papillary muscles following BTT. Preoperative transesophageal echocardiography (TEE) diagnosed the delayed mitral papillary muscle rupture while all previous diagnostic modalities failed to delineate the pericardial rupture and cardiac herniation. Particular emphasis is placed on the clinical and radiologic aspects of the case that would heighten clinical suspicion in the emergency setting where blunt cardiac injury sequelae are suspected and frequently missed.

Trauma of the Pericardial Sac and Heart: An Autopsy Series

From 145 consecutive autopsies on traffic fatalities and leaps from heights performed by one author were found 38 cases with laceration of the heart, laceration of the pericardial sac, or contusion of the heart. Twenty-eight subjects had pericardial laceration: 13 of the left side singly, eight of the right side singly, one of the anterior wall singly, and six with multiple lacerations. Five of the 13 had herniation of the heart into a pleural cavity. Twenty-one of the 38 had laceration of the heart; 12 multiple and nine singly. The lacerations were equally distributed between atria and ventricles but almost all the atrial lacerations involved the right atrium. Thirteen of the 38 subjects had contusion of the heart in the absence of a cardiac laceration. Two of them also had a sprain injury of the intrapericardial portion of the inferior vena cava. The contusions were in epicardial fat depots in the atrioventricular sulci and along the acute and obtuse margins of the heart. None of the contusions was confined to the myocardium. Eleven of the 38 had a sternal fracture and 30 had rib fractures. Major craniocervical trauma and lacerations of the liver, spleen, aorta, and lung were common. Only six of 38 ever had a pulse after the crash or leap. The longest survival was 3.75 hours.

Pericardial lacerations most commonly occurred in the unbuttressed parts of the pericardium, namely, the left and right pleuropericardia. Pericardial laceration is essentially a traumatic rupture caused when the heart is compressed between the sternum and vertebral column and the sac gives way.

Traumatic pericardial rupture with cardiac herniation

If undiagnosed, traumatic pericardial rupture with herniation of the heart may have fatal consequences. We report two cases of multiple trauma with pericardial rupture, which was missed in the preoperative diagnoses of both patients, in spite of suggestive signs on computed tomographic scans. One patient had unexplained, persistent hemodynamic instability; the second patient had cardiac arrest during laparotomy for minor hepatic laceration. In both, the left-sided rupture of the pericardium with cardiac herniation into the pleural space was found and corrected in an emergency intervention. Both patients recovered completely.

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.

Imaging of cardiac herniation in traumatic pericardial rupture

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.

Traumatic pericardial rupture without cardiac injury

Pericardial rupture is a rare injury following blunt chest trauma. It is frequently fatal because of serious complications such as cardiac herniation and/or contusion. We report a case of traumatic pericardial rupture without cardiac injury, which was incidentally identified intraoperatively. A 63-year-old woman was transported to the hospital after sustaining blunt chest trauma from a motor vehicle accident. Radiographic workup demonstrated multiple fractures, pulmonary contusion, and hemopneumothorax. A chest tube was inserted, and persistent bleeding was observed. An exploratory thoracotomy was performed, and active pulmonary bleeding was controlled. Further exploration revealed major pericardial rupture without cardiac herniation or intrapericardial injury, which was repaired by a bovine pericardial patch. Her postoperative course was uneventful. It is usually difficult to make a diagnosis of pericardial rupture, and a misdiagnosis often leads to a fatal consequence. Therefore, an immediate surgical exploration is warranted if clinical and radiographic findings suggest the condition.