Acute herniation of the heart following pneumonectomyAP Chaukar, AS Swarup, NV Mandke, GB Parulkar, SR Panday
Department of Cardiovascular and Thoracic Surgery, K. E. M. Hospital, Parel, Bombay-400 012, India
This is a case report of acute herniation of heart following right pneumonectomy done for bronchiectasis. The clinical picture, diagnostic criteria and treatment o f this acute life threatening condition is described. Early diagnosis and prompt correction, as done in this case, yields rewarding result.
Herniation of the heart through a pericardial defect following resectional surgery of the lung is a rare occurrence. World literature records only 35 such cases all of which were for neoplastic disease. ,,,,,,,,, We have encountered this complication following a right pneumonectomy for a case of bronchiectasis. The pericardial defect was created as a result of slipped ligature of the inferior pulmonary vein necessitating its intrapericardial suturing. This, to our belief, is the first case of herniation of the heart following pneumonectomy for bronchiectasis.
A 13 year old boy was admitted to the K.E.M. Hospital, Bombay, in May, 1975 for dyspnea and productive cough of 6 years' duration. Physical examination and radiological studies pointed to a diagnosis of cystic bronchiectasis of the right lung. A bronchogram confirmed the diagnosis and revealed a normal pattern of the left lung See [Figure 1] on page 142b. Pre-operative physiotherapy and antibiotics were instituted and the patient was posted for a right pneumonectomy.
In the right lateral position under general anaesthesia the chest was opened through the 6th rib bed. The lung was mobilized without any difficulty. The pulmonary artery was cut between two proximal and one distal ligature. The proximal end was reinforced with 4-0 merselene transfixation suture. The superior pulmonary vein was dealt with in a similar fashion. At the time of, transfixing the inferior pulmonary vein the two proximal ligatures slipped. The consequent bleeding from the left atrium was controlled by finger pressure. The pericardium was then opened in order to have a better exposure. The left atrium along with a part of the pericardium was then held in an angled atraumatic clamp. The opening of the inferior pulmonary vein in the left atrium was then sutured with 4-0 merselene. This suture line included the pericardial reflection at the base of the inferior pulmonary vein. The bronchus was sutured using clips. There was no bleeding from the hilum.
The repair of the inferior pulmonary vein resulted in an oval defect in the pericardium measuring 6 cm x 4 cm. The margins of the pericardium were approximated with three sutures. This approximation was facilitated by mobilizing the pleura overlying the azygous vein. The chest was closed in layers with a drain. The drainage tube was kept clamped. Two units of blood were needed during surgery.
On reversal from anaesthesia the patient was semiconscious having a feeble pulse and nonrecordable blood pressure. Riles were heard all over the left lung suggesting pulmonary edema and hence was given steroids, frusemide and mannitol. His breathing remained unsatisfactory and hence he was maintained on positive pressure respiration with 100% oxygen. An adrenaline drip (4 ampoules in 500 ml of dextrose) was started to support his heart.
His condition failed to improve. He developed cyanosis, puffiness of the face and a very high C.V.P. (more than 30 cm of water). An emergency X-ray of the chest taken at this stage revealed a shadow on the right side See [Figure 2] on page 142b.
We attributed the cardiorespiratory embarrassment to acute cardiac tamponade and the patient was explored. On exploration there was no cardiac tamponade. The interrupted sutures approximating the margins of the pericardium to the pleural flap had snapped. The right atrium with its appendage, the right ventricle and a part of the left atrium had herniated through this defect. This caused a severe kinking of both the cavae resulting into low cardiac output.
The heart was replaced within the pericardium. As it was not possible to bridge the gap in the pericardium it was widely excised to prevent a recurrence of herniation.
The patient was on a respirator overnight. This caused mediastinal movement which was countered by repeated positive and negative pressures applied through the drainage tube on the operated side. The patient was extubated next morning. In order to reduce the respiratory effort a tracheostomy was done.
The drainage tube was removed on the third postoperative day after the mediastinum had stabilized. The tracheostomy was removed on the fourth day.
On the 11th post-operative day the patient had a burst thorax which was sutured.
The patient was discharged on the 22nd postoperative day, When last seen (twenty months after surgery) he was doing well See [Figure 3] on page 142b.
Acute herniation of the heart following pneumonectomy is a rare but known complication. This complication follows the creation of a pericardial defect following intra-pericardial ligation of pulmonary vessels or excision of a part of pericardium due to neoplastic involvement.
The herniation usually occurs in the immediate post-operative period and appears to be related to the negative intrapleural pressure, application of chest tube suction, positive pressure breathing, tracheal aspiration, coughing or a change in position of the patient during transport from the operation theatre to the recovery area. ,
Chest X-rays in the immediate postoperative period are diagnostic but during the crisis of circulatory collapse, time may not allow their use or meaningful interpretation. Radiologically, the essential features are displacement of the cardiac mass into the operated side or a change in the roentgenographic configuration, depending upon the completeness of the herniation. There may be a constriction between the cardiac mass and the great vessels with the heart assuming a spherical shape.
Recognition is quick if the possibility is kept in mind. The common manifestations are sudden profound hypotension, cyanosis, and distension of the neck veins. The apex beat may be feeble and shifted in location. The mechanism of hypotension appears to be due to torsion and kinking of the cavae resulting in reduced venous return. Outflow tract obstruction may also contribute.
The immediate differential diagnosis includes massive intrathoracic haemorrhage, atelectasis of the remaining lung and acute cardiac tamponade.
Total herniation of the heart through congenital pericardial defects has been described only on the left side. In all such cases described, the defect was situated in the upper part of the pericardium. Total herniation of the heart has not been reported in patients with complete absence of the left pericardium, as in these cases the heart is free to move in the common pleuro-pericardial cavity and does not get strangulated. 
Treatment is directed at immediate repositioning of the heart and closure of the defect. Pleural flaps, fascia lata and teflon have been used to repair the pericardial defect. ,, Alternatively enlarging the gap or excising the pericardium widely has been recommended by many. ,,,,,,,, [9,
The case reported here has been the only case seen at our centre in the last 20 years. The globular shadow in chest X-ray, raised venous pressure, severe hypotension, cyanosis were the pointers to the diagnosis. The emergency exploration was however undertaken with a diagnosis of acute cardiac tamponade.
We followed the technique of enlarging the gap by excising the pericardium widely. This resulted in mediastinal movement in the immediate post-operative period which was appropriately dealt with.
This serious complication of herniation of heart, we feel, is preventable if the created pericardial defect is suitably dealt with at the primary operation.
[Figure 1], [Figure 2], [Figure 3]