Sudden Dextrocardia? Traumatic Rupture of the Pericardium With Associated Cardiac Herniation

Juan Biguria, MD; Diego Maselli, MD; Julian Salas Millan, MD

INTRODUCTION: Blunt traumatic rupture of the pericardium (BTRP) with associated cardiac herniation is an unusual and often fatal condition. Despite being a recognized complication of blunt chest trauma, the majority of cases have been identified postmortem. We present a patient who suffered high-energy blunt force thoracic trauma leading to pericardial rupture with cardiac herniation.

CASE PRESENTATION: A 22 year-old man with no previous history sustained a fall from the top of a 7-story building. On arrival the patient was comatose with bilateral chest subcutaneous emphysema. Chest radiography revealed multiple rib fractures with bilateral pneumothoraces, pneumopericardium and complete right-sided deviation of the cardiac silhouette. (Figure 1). Several cervical, pelvic and long bone fractures were identified. Bilateral chest tubes were placed. A chest tomography revealed persistent pneumothoraces and pneumopericardium with displacement of the cardiac structures to the right (Figure 2). The patient became hemodynamically unstable and was taken to the operating room. A median sternotomy revealed a 10cm vertical defect on the right pericardium at the level of the phrenic nerve with displacement of the entire heart into the right pleural space. The heart was mobilized back to its normal anatomic position. No great vessel or cardiac injury was identified. The pericardial defect was repaired with a Gore-Tex patch. Hemodynamic stability was recovered soon after. The patient survived surgery and is recovering from his injuries.

DISCUSSION: Pericardial rupture after blunt chest trauma has a reported incidence of 0.4% to 3%. If the heart herniates through the rupture, only approximately one third of patients will survive. Death occurs from torsion at the atrial level, which results in inflow occlusion with consecutive cardiac arrest, or compression of the coronary arteries. In this case there was delay in the diagnosis due to the abundance of other extrathoracic injuries. Nevertheless after prompt surgical repair his condition improved significantly. BTRP's high mortality is thought to be not only due to cardiac injury and herniation, but also due to associated injuries and delays in diagnosis.

CONCLUSIONS: BTRP with associated cardiac herniation is rare and difficult to diagnose. It should be suspected in every case of severe blunt chest trauma, particularly if there is hemodynamic instability.

Chest. 2015;148(4_MeetingAbstracts):42A. doi:10.1378/chest.2271662