Cardiac herniation producing tamponade: the critical role of early diagnosis

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.

Blunt traumatic rupture of the pericardium with cardiac herniation

Traumatic rupture of the pericardium with cardiac herniation is rare. Clinicians are often unfamiliar with the clinical and radiological manifestations of the injury, and the diagnosis is frequently missed preoperatively. This case report describes a patient with multiple trauma following a fall from a height, who developed this injury. The diagnosis was not made preoperatively despite suggestive clinical, electrocardiographic and radiological findings. Clinicians need to be aware of the presentation of this potentially fatal injury so that the diagnosis can be made and treatment instituted at an earlier stage. Pericardial rupture with cardiac herniation presents as cardiogenic shock, mimicking cardiac tamponade.

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.

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.

Thoracoscopy for the acutely injured patient

Advances in video-surgery digital technology, new instruments, and advanced surgical techniques have increased the importance of video-assisted thoracoscopic surgery (VATS) in the diagnosis and treatment of the acutely injured patient. Currently, VATS offers a new approach in the diagnosis and treatment of many thoracic conditions previously treated only by standard thoracotomy. Available data suggest that when caring for trauma patients, results of VATS are comparable with open surgery. Furthermore, the recovery process clearly is expedited with this minimally invasive modality. It has been our experience during the last decade that VATS is a safe, reliable, and effective alternative to conventional open thoracic surgery.

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 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.