Pericardial rupture leading to cardiac herniation after blunt trauma

Abstract

Pericardial rupture with cardiac herniation is a rare traumatic injury with an estimated incidence of 0.37% after blunt trauma. Most commonly occurring after high-speed impact, such as in motor vehicle or motorcycle collisions, pericardial rupture is associated with a high mortality rate. Radiologic diagnosis can be challenging; cross-sectional imaging findings can be suggestive of pericardial rupture but are often non-specific, and echocardiography windows are often obscured. Definitive diagnosis is generally made intra-operatively. Treatment involves reduction of the heart into normal anatomic position with repair of the pericardium, either primarily or with a patch. Fewer than 60 cases of pericardial rupture from blunt trauma have been reported in the literature. We describe a 65 year old poly-trauma patient who sustained pericardial rupture with subsequent cardiac herniation with cardiovascular collapse, and we discuss the considerations and complexities of his successful repair.

Keywords: Cardiac herniation; Cardiac subluxation; Cardiac trauma; Pericardial rupture.

Fig. 1

Initial chest x-ray obtained in the trauma bay. The white arrow shows a large gastric bubble projecting over the heart, raising the suspicion for a diaphragmatic injury in the setting of blunt trauma.

Fig. 2

Representative images from the patient's chest CT scan. (A) A coronal view with multiple arrows highlighting pneumopericardium within the pericardial recesses. (B) An axial view highlighting pneumopericardium with some compressive effects on the anterior aspect of the heart.

Fig. 3

Intraoperative photo demonstrating a large left sided pericardial defect, highlighted by the black arrow. The patient's head is oriented towards the left of the image. Lung tissue can be seen through the defect. The posterior pericardium is detached and is pulled anterior by the surgical instrument.

Fig. 4

Intraoperative photo demonstrating anterior/medial elevation of the cardiac apex using a Medtronic® “urchin heart-positioner” to allow exposure for pericardial repair. The patient's head is oriented towards the right of the image.