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Home > Blogs > Karim's Weblog > Something’s not quite right… episode 3

As some of you have surmised this is a typical (if rare) picture of cardiac herniation.  This is not dextrocardia/situs as the anatomy of the aortic arch is normal.  Also the high vasopressor requirement suggests that this is not normal for the patient!  Similarly the picture is not typical of other postulated causes such as tension pneumothorax, tension pneumomediastinum, tension pneumopericardium etc.  The patient was taken to the operating room.  A left anterolateral thoractomy incision was performed and the pericardium opened.  The pericardium was empty which confirmed the diagnosis.  The incision was extended into a full clamshell incision.

dc05

dc06

The heart was twisted on the SVC/IVC axis and was oedematous and engorged.  The right phrenic nerve was intact but torn free from the pericardium.  The preidcardial tear was widened and the heart relocated, with a good return in blood pressure and a decrease in vasopressor requirements.

dc07

The right lateral tear in the pericardium was closed to avoid the heart re-twisting into the right chest.  The surgical pericardial incision was left widely open as the heart was too engorged for it to be closed.  The clamshell incision was closed and the patient taken to the intensive care unit for further management.

Cardiac herniation is rare but is a correctable cause of traumatic arrest or profound hypotension and must be considered.  There are several cases in the literature and two case reviews [PMIDs 9253902 and 16096553].  The Chest X-ray and CT findings of a right-sided herniation are clear here, although many are left-sided and the chest X-ray may be normal.

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