PDF(Pubmed)
Abstract：
BACKGROUND: Cardiac herniation occurs when there is a residual pericardial defect post thoracic surgery and is recognised as a rare but fatal complication. It confers a high mortality and requires immediate surgical correction upon recognition. We present a case of cardiac herniation occurring post thymectomy and left upper lobectomy.
METHODS: Initial presentation: A 48-year-old male, hypertensive smoker presented with progressive breathlessness and was found to have a left upper zone mass confirmed on CT biopsy as carcinoid of unclear origin. PET-CT revealed avidity in a left anterior mediastinal area, left upper lobe (LUL) lung mass, mediastinal lymph nodes, and a right thymic satellite nodule. Intraoperatively: Access via left thoracotomy and sternotomy. The LUL tumour involved the left thymic lobe (LTL), left superior pulmonary vein (LSPV), left phrenic nerve and intervening mediastinal fat and pericardium, which were resected en-masse. The satellite nodule in the right thymic lobe (RTL) was adjacent to the junction between the left innominate vein and superior vena cava (SVC). The pericardium was resected from the SVC to the left atrial appendage. Clinical deterioration: Initially the patient was doing well clinically on day 1, however there was sudden bradycardia, hypotension, clamminess, and oligoanuria, with raised central venous pressures and troponins. ECG: no capture in leads V1-2, but positive deflections seen on posterior leads. Echo: no acoustic windows, but good windows seen posteriorly. CXR: left mediastinal shift. Redo operation: After initial resuscitation and stabilisation on the intensive care unit, on day 2 a redo-sternotomy revealed cardiac herniation into the left thoracic cavity with the left ventricular apex pointing towards the spine, and inferior caval kinking. After reduction and repair of the pericardial defect with a fenestrated GoreTex patch, the patient recovered well with complete resolution of the ECG and CXR.
CONCLUSIONS: Cardiac herniation can even occur following sub-pneumonectomy lung resections and should be considered as a differential when faced with a sudden clinical deterioration, warranting early surgical correction.
METHODS: Initial presentation: A 48-year-old male, hypertensive smoker presented with progressive breathlessness and was found to have a left upper zone mass confirmed on CT biopsy as carcinoid of unclear origin. PET-CT revealed avidity in a left anterior mediastinal area, left upper lobe (LUL) lung mass, mediastinal lymph nodes, and a right thymic satellite nodule. Intraoperatively: Access via left thoracotomy and sternotomy. The LUL tumour involved the left thymic lobe (LTL), left superior pulmonary vein (LSPV), left phrenic nerve and intervening mediastinal fat and pericardium, which were resected en-masse. The satellite nodule in the right thymic lobe (RTL) was adjacent to the junction between the left innominate vein and superior vena cava (SVC). The pericardium was resected from the SVC to the left atrial appendage. Clinical deterioration: Initially the patient was doing well clinically on day 1, however there was sudden bradycardia, hypotension, clamminess, and oligoanuria, with raised central venous pressures and troponins. ECG: no capture in leads V1-2, but positive deflections seen on posterior leads. Echo: no acoustic windows, but good windows seen posteriorly. CXR: left mediastinal shift. Redo operation: After initial resuscitation and stabilisation on the intensive care unit, on day 2 a redo-sternotomy revealed cardiac herniation into the left thoracic cavity with the left ventricular apex pointing towards the spine, and inferior caval kinking. After reduction and repair of the pericardial defect with a fenestrated GoreTex patch, the patient recovered well with complete resolution of the ECG and CXR.
CONCLUSIONS: Cardiac herniation can even occur following sub-pneumonectomy lung resections and should be considered as a differential when faced with a sudden clinical deterioration, warranting early surgical correction.
摘要：
背景：当胸外科手术后有残余的心包缺损时，就会发生心脏疝，被认为是一种罕见但致命的并发症。它具有很高的死亡率，并且需要在识别后立即进行手术矫正。我们介绍了一例胸腺切除术和左上叶切除术后发生的心脏疝。
方法：初次陈述：一名48岁男性，高血压吸烟者表现为进行性呼吸困难，发现左上区肿块经CT活检证实为起源不明的类癌。PET-CT显示左前纵隔区域亲合力，左上叶（LUL）肺肿块，纵隔淋巴结，还有一个右胸腺卫星结节.术中：通过左侧开胸和胸骨切开术进入。LUL肿瘤累及左胸腺叶（LTL），左上肺静脉(LSPV),左膈神经和纵隔脂肪和心包，被大规模切除。右胸腺叶（RTL）的卫星结节与左无名静脉和上腔静脉（SVC）之间的交界处相邻。将心包从SVC切除至左心耳。临床恶化：最初患者在第1天临床表现良好，但突然出现心动过缓，低血压,喧闹，和少尿症，中心静脉压和肌钙蛋白升高。心电图：V1-2导联没有捕获，但在后导联上看到正偏转。回声:没有声音窗口，但是从后面可以看到好的窗户。CXR：纵隔左移。重做手术：在重症监护病房进行初步复苏和稳定后，第2天，胸骨重切术显示心脏疝进入左胸腔，左心室心尖指向脊柱，和下静脉扭结。在用开窗的GoreTex补片减少和修复心包缺损后，患者恢复良好，心电图和CXR完全恢复。
结论：肺切除术后甚至会发生心脏疝，当面临突然的临床恶化时，应将其视为一种差异。保证早期手术矫正。
方法：初次陈述：一名48岁男性，高血压吸烟者表现为进行性呼吸困难，发现左上区肿块经CT活检证实为起源不明的类癌。PET-CT显示左前纵隔区域亲合力，左上叶（LUL）肺肿块，纵隔淋巴结，还有一个右胸腺卫星结节.术中：通过左侧开胸和胸骨切开术进入。LUL肿瘤累及左胸腺叶（LTL），左上肺静脉(LSPV),左膈神经和纵隔脂肪和心包，被大规模切除。右胸腺叶（RTL）的卫星结节与左无名静脉和上腔静脉（SVC）之间的交界处相邻。将心包从SVC切除至左心耳。临床恶化：最初患者在第1天临床表现良好，但突然出现心动过缓，低血压,喧闹，和少尿症，中心静脉压和肌钙蛋白升高。心电图：V1-2导联没有捕获，但在后导联上看到正偏转。回声:没有声音窗口，但是从后面可以看到好的窗户。CXR：纵隔左移。重做手术：在重症监护病房进行初步复苏和稳定后，第2天，胸骨重切术显示心脏疝进入左胸腔，左心室心尖指向脊柱，和下静脉扭结。在用开窗的GoreTex补片减少和修复心包缺损后，患者恢复良好，心电图和CXR完全恢复。
结论：肺切除术后甚至会发生心脏疝，当面临突然的临床恶化时，应将其视为一种差异。保证早期手术矫正。
