Unexpected postoperative course after 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.

Left ventricular aneurysm with herniation through the chest wall

Cardiac herniation is a rare event associated with a high mortality rate. It is typically seen with blunt trauma to the chest or after a pneumectomy. Signs and symptoms include arrhythmia, myocardial ischemia, and hypotension. Diagnostic modalities, such as computed tomography scan, chest roentgenogram, magnetic resonance imaging, and transthoracic and transesophageal echocardiography, are key to diagnosis. Successful management requires timely recognition along with prompt surgical intervention.

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.

Cardiac herniation and volvulus with acquired dextrocardia: echocardiographic diagnosis

We report an extremely rare cause of elevated jugular venous pulse where two esoteric causes for the same-cardiac volvulus and cardiac herniation have occurred together. Echocardiographic evidence for making the diagnosis of cardiac volvulus--subcostal long axis, subcostal short axis, and suprasternal views--have been presented. Awareness of this complication is necessary as immediate intervention is mandatory for a positive outcome.

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.

Acute postoperative compromise in cardiovascular function after chest surgery

Attention to preoperative cardiovascular risk factors, appropriate preparation, early recognition, and treatment are essential to prevent potential catastrophic cardiac events from leading to life-threatening situations in the postoperative period.