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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 3  |  Page : 249-252
Cardiac herniation following completion pneumonectomy for bronchiectasis


1 Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala - 695 011, India
2 Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala - 695 011, India

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Date of Submission15-Dec-2009
Date of Acceptance27-May-2010
Date of Web Publication6-Sep-2010
 

   Abstract 

Sporadic reports on cardiac herniation are available in the literature; most of them had followed intrapericardial pneumonectomies for malignant pulmonary tumors. We present an uncommon event of heart herniation after a completion pneumonectomy indicated for chronic bronchiectasis. A 35-year-old male patient was operated for left completion pneumonectomy. A 6 cm Χ 4 cm area of adherent pericardium near the obtuse margin of heart was removed during surgery. During head-end elevation of the bed in postoperative intensive care unit, patient got accidentally tilted to the left side, which resulted in ventricular fibrillation. Chest cavity was re-opened for cardiopulmonary resuscitation. Left ventricle was found herniating through the pericardial deficiency into the left-thoracic cavity with the cardiac apex touching chest wall. During surgical re-exploration, the pericardial deficiency was closed with a synthetic Dacron patch. Hemodynamic condition remained stable in the immediate postoperative period. Patients had infection of the left thoracic cavity after 5 weeks, for which he was subjected to thoracoplasty and omentopexy. Prompt recognition with timely intervention is life saving from cardiac herniation. Strategy of closing the pericardial defect after pneumonectomy should be followed routinely, irrespective of the indication for pneumonectomy.

Keywords: Cardiac herniation, bronchiectasis, pneumonectomy

How to cite this article:
Gadhinglajkar S, Siddappa S, Sreedhar R, Madathipat U. Cardiac herniation following completion pneumonectomy for bronchiectasis. Ann Card Anaesth 2010;13:249-52

How to cite this URL:
Gadhinglajkar S, Siddappa S, Sreedhar R, Madathipat U. Cardiac herniation following completion pneumonectomy for bronchiectasis. Ann Card Anaesth [serial online] 2010 [cited 2020 Jan 25];13:249-52. Available from: http://www.annals.in/text.asp?2010/13/3/249/69045



   Introduction Top


Cardiac herniation is a rare complication encountered after an intrapericardial pneumonectomy. Sporadic reports on cardiac herniation are available in the literature; most of them have followed the pneumonectomies for malignant pulmonary tumors. [1],[2] We present an uncommon event of heart herniation after a completion pneumonectomy indicated for chronic pulmonary infection.


   Case Report Top


A 35-year-old male patient who had chronic bronchiectasis underwent left lower lobectomy 20 years ago. His current admission was for the symptoms of recurrent hemoptysis, and frequent respiratory infections during the last 4 years. He was scheduled for left completion pneumonectomy. Preoperative X-ray and CT scan of chest revealed hyperinflated right lung; collapsed left upper lobe; and totally hazy left hemithorax with indistinct cardiac silhouette [Figure 1]. After induction of anaesthesia, the left lung was isolated using left sided 39 F double lumen tube (DLT). Correct placement of the DLT was confirmed using fibreoptic bronchoscopy. A left posterior thoracotomy was performed, which revealed a collapsed residual lung that was adherent to the pericardium. The left thoracic cavity was almost obliterated due to extensive adhesions and a leftward displaced heart. Completion pneumonectomy was performed along with removal of a 6 cm Χ 4 cm area of adherent pericardium near the obtuse margin of heart. The deficient pericardial defect was left unrepaired as the heart was abutting against the chest wall. As postoperative elective ventilation was contemplated, the DLT was changed over to a 9 mm endotracheal tube at the end of the surgery. Patient was transferred to the intensive care unit (ICU) with stable hemodynamic parameters.
Figure 1: Preoperative X-ray chest is showing a collapsed left upper lobe; leftward displacement of mediastinum (arrow pointing leftward displacement of trachea); and hyperinflated right lung

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The patient was placed supine and ventilated on a pressure controlled mode in the ICU. Patient had a stable hemodynamic condition, with heart rate and blood pressure of 84/ minute and 126/ 80 mmHg. During head-end elevation of the bed to 30-degrees, patient got accidentally tilted to the left side, which resulted in instant precipitous hypotension and bradycardia. Epinephrine infusion 0.1 mcg/ kg/ min was commenced; however, within a couple of minutes ventricular fibrillation ensued. As attempts to resuscitate the patient with cardiac defibrillations, 2 bolus injections of 1 mg epinephrine and closed chest massage failed, chest cavity was re-opened. Left ventricle was found herniating through the pericardial deficiency into the left-thoracic cavity with the cardiac apex touching chest wall, although, there was no evidence of myocardial strangulation. Sinus rhythm was resumed and hemodynamic condition improved significantly after placing the heart to its original position. Patient was transported back to the operation suite in a right lateral decubitus with infusion of epinephrine 0.1 mcg/ kg/ min and norepinephrine 0.05 mcg/ kg/ minute. During re-exploration, the pericardial deficiency was closed with a synthetic Dacron patch. Hemodynamic condition remained stable in the postoperative period. Trachea was extubated after 8 hours of elective ventilation and the inotropic infusions were weaned off over next 12 hours. Patient had a smooth recovery and was discharged from the hospital on 10 th postoperative day. However he returned after 5 weeks with infection of the thoracic space. X-ray and CT scan of chest revealed fluid collection [Figure 2]. Following intercostal drain insertion and treatment with broad spectrum antibiotics, proactive thoracoplasty was performed along with omentopexy. The Dacron patch could be removed as the pericardial adhesions had stabilized the heart, which was further supported by the removal of ribs that collapsed the chest cavity inward. His subsequent recovery was uneventful and at 18-month follow up, he is keeping a good health.
Figure 2: (a) Fluid level (arrow) and over-expanding right lung reaching contralateral side (arrow head) are seen in the X-ray chest after pneumonectomy. (b) A post-pneumonectomy CT scan is revealing the Dacron-pericardioplasty patch (arrow), and an obliterated pleural cavity

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   Discussion Top


Cardiac herniation occurs typically when the surgically created pericardial defect is not closed. The incidence of heart displacement has been found independent of the size of the defect and without any side predilection. [1] As strangulation remains the main cause for the hemodynamic worsening after the left-sided herniation, some authors believe that wide opening the pericardial defect solves the problem. [3],[4] Contrary to that, there are proponents of pericardioplasty, who advise closure of the defect irrespective of its size, to prevent cardiac herniation after pneumonectomy. [5],[6] In majority of the reported incidents of heart herniation, patients were subjected to intrapericardial pneumonectomies for lung malignancy. [1],[2] Extended pericardial resection, and reinforcement of the bronchial stump [7] using a pericardial flap or a pericardiophrenic flap, is routinely performed in many of them. The resulting pericardial deficiency makes them prone for the development of cardiac herniation. It is extremely rare in the literature to confront with an episode of cardiac herniation occurring in patients with pneumonectomy indicated for chronic pulmonary infections. Unlike harvesting a pericardial flap in patients with pneumonectomies for the lung malignancies, bronchial stumps in post-infectious pneumonectomies were buttressed with transposed Latissimus dorsi or intercostal muscle flaps. [8],[9] Even though, pericardium was opened in a few cases, the incision was limited to access the hilar structures, which probably explains the absence of cardiac herniation in these patients. The adherent pericardial portion over the obtuse margin of heart was excised in our patient. As the cardiac apex was abutting against the chest wall following pneumonectomy, we believed that it would prevent heart from herniating through the defect.

Heart-herniation may present when the patient is turned supine at the conclusion of the operation or in the very early postoperative period, usually within the first 24 hours. Factors precipitating it are application of negative pressure to the thoracostomy drainage tubes, positive pressure ventilation, coughing on extubation and positioning the patient with operated side dependent. [10],[11] Mechanism of hemodynamic deterioration differs between the cardiac herniation occurring on the right-side and left-side of the thoracic cavity. In right-sided herniation, dextrorotation of heart results in the torsion of the atrio-caval junctions and great vessels and the ventricular outflow tract obstruction, leading to a dramatic fall in cardiac output. Left-sided herniation leads to strangulation of the ventricular muscles and pressure over coronary arteries by the edges of the pericardial defect. The extrapericardial myocardium becomes ischemic and edematous. If the strangulation is not relieved quickly, it leads to fatal ventricular outflow obstruction, arrhythmia and myocardial infarction.

Considering the fact that cardiac herniation after pneumonectomy carries a high mortality rate of 50%, despite a prompt management, [11] early recognition is pivotal. X-ray signs on the right-side are often more striking with displacement of the cardiac apex into the right chest cavity. There may also be associated displacement of any thoracostomy tube, a sharp kink in any central venous line or a clockwise rotation of any pulmonary artery catheter. [12] The left-sided-herniation is seen on X-ray as a rounded opacity in the lower part of the left hemithorax caused by the strangulated ventricular mass in addition to the left shift of the cardiac shadow. The apex may contact the lateral chest wall or be posteriorly directed into the posterior costophrenic sulcus. [6] Echocardiography offers a relatively easy and non-invasive additional technique for confirming or supporting the diagnosis. Transthoracic echo has limitations in the left sided herniation because of loss of windows due to immediate surgery. Transesophageal echocardiography may be suitable for cardiac visualization in such situation. However, time may not permit X-ray and echocardiographic evaluation if patient deteriorates rapidly, as in our case. Therefore, possibility of the cardiac herniation should be kept in mind whenever the posterolateral pericardium is made deficient after surgery.

Three conservative measures to improve the cardio-respiratory function before patient transfer to the operation suite include repositioning the patient with nonsurgical side down, avoiding hyperinflation of the remaining lung and injecting 1-2 liters of air into the surgical hemithorax. [10] Definitive treatment and prevention of recurrence require open surgery to reduce the hernia and repair the pericardial defect by prosthetic patch or autologous graft like fascia lata. Thoracic cavity infection remains a major issue with pericardial patch repair, more when a synthetic material is used than an autologous tissue. [5] Thoracoplasty supplemented with omentopexy helps to obliterate the intrathoracic cavity.

In summary, cardiac herniation is uncommonly reported sequelae after pneumonectomies for lung tumors; and very rarely following completion pneumonectomy for bronchiectasis. Prompt recognition with timely intervention is life saving from this complication. Strategy of closing the pericardial defect after pneumonectomy should be followed routinely, irrespective of the indication for pneumonectomy.

 
   References Top

1.Veronesi G, Spaggiari L, Solli PG, Pastorino U. Cardiac dislocation after extended pneumonectomy with pericardioplasty. Eur J Cardiothorac Surg 2001;19:89-91.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Rodenwaldt J, Lembcke AE, Wiese TH, Hφhn S, Hamm BK. Postoperative dislocation of the heart after pneumonectomy. Circulation 2002;105:e49-50.  Back to cited text no. 2      
3.Levin PD, Faber LP, Carleton RS. Cardiac herniation after pneumonectomy. J Thorac Cardiovasc Surg 1971;61:104-6  Back to cited text no. 3      
4.Papsin BC, Gorenstein LA, Goldberg M. Delayed myocardial laceration after intrapericardial pneumonectomy. Ann Thorac Surg 1993;55:756-7.  Back to cited text no. 4  [PUBMED]    
5.Kageyama Y, Suzuki K, Matsushita K, Nogimura H, Kazui T. Pericardial closure using fascia lata in patients undergoing pneumonectomy with pericardiectomy. Ann Thorac Surg 1998;66:586-7.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Deiraniya AK. Cardiac herniation following intrapericardial pneumonectomy. Thorax 1974;29:545-52.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Taghavi S, Marta GM, Lang G, Seebacher G, Winkler G, Schmid K, et al. Bronchial stump coverage with a pedicled pericardial flap: An effective method for prevention of postpneumonectomy bronchopleural fistula. Ann Thorac Surg 2005;79:284-8.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Sherwood JT, Mitchell JD, Pomerantz M. Completion pneumonectomy for chronic mycobacterial disease. J Thorac Cardiovasc Surg 2005;129:1258-65.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Mitchell JD, Bishop A, Cafaro A, Weyant MJ, Pomerantz M. Anatomic lung resection for nontuberculous mycobacterial disease. Ann Thorac Surg 2008;85:1887-92.   Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Cassorla L, Katz JA. Management of cardiac herniation after intrapericardial pneumonectomy. Anesthesiology 1984;60:362-4.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Chambers N, Walton S, Pearce A. Cardiac herniation following pneumonectomy--an old complication revisited. Anaesth Intensive Care 2005;33:403-9.  Back to cited text no. 11  [PUBMED]    
12.Brady MB, Brogdon BG. Cardiac herniation and volvulus: Radiographic findings. Radiology 1986;161:657-8.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Shrinivas Gadhinglajkar
Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala - 695 011
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.69045

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