Cardiac Herniation following Pneumonectomy—An Old Complication Revisited

Abstract

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.

Cardiac herniation following completion pneumonectomy for bronchiectasis

“…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 rightside 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.…”

A case of cardiac herniation after extrapleural pneumonectomy for malignant thymoma

“…Echocardiography is noninvasive and is available at the bedside to confirm or support the diagnosis. Echocardiographic findings include a mass effect of the pericardium in elongation and compression of the atrium, and the ventricle can appear bulbous and distorted [8]. In this patient, cardiac herniation possibly occurred when the patient was turned to the supine from the lateral decubitus position.…”

“…More than 50 cases of cardiac herniation after intrapericardial pneumonectomy have been reported since 1948 [7,8]. Although it can occur as a result of any size of pericardial defect, as reported previously, a larger defect may cause this complication more frequently.…”

Management of Complications After Pneumonectomy

“…46 Hemodynamic collapse following a change in patient positioning should heighten the clinical suspicion of cardiac herniation. 55 Following successful resuscitation, the patient is taken back to the operating room (if not already there) for a washout and correction of the cause of herniation.…”