Pericardial Rupture with Intermittent Cardiac Luxation

A 70-year-old man who had been in a motor vehicle accident presented in hemodynamically stable condition. A chest radiograph revealed nothing notable (Fig. 1A), and results on routine pericardial ultrasound were inconclusive. A chest computed tomogram revealed evidence of a right-sided heart injury with pneumopericardium, hemopneumothorax, multiple rib fractures, and possible intravenous contrast medium in the pericardium (Fig. 1B). A transesophageal echocardiogram (TEE) showed right-sided heart dysfunction and a small pericardial effusion. A right-sided chest tube evacuated 300 mL of blood.

Fig. 1.

At hospital admission, A) chest radiograph shows a normal cardiac silhouette. B) Computed tomogram shows possible right-sided heart extravasation (arrow).

A subsequent chest radiograph showed the patient's cardiac silhouette in his right hemithorax (Fig. 2A). An emergency computed tomogram confirmed cardiac luxation into the right hemithorax, from cardiac herniation through a pericardial tear (Fig. 2B). Cardiophrenic fat herniation, cardiac torsion, and pericardial dimpling were consistent with this type of a tear.

Fig. 2.

Hospital day 1. A) Chest radiograph shows the heart shifted into the right hemithorax. B) Corresponding computed tomogram shows cardiac luxation, cardiophrenic fat herniation (arrowhead), and pericardial dimpling (arrows).

The patient was hemodynamically stable except when lying in the right lateral decubitus position. His orthopedic injuries were sequentially repaired. On hospital day 8, we performed diagnostic right thoracoscopy and then median sternotomy for bovine pericardial patch repair of a 5-cm right inferior lateral pericardial defect and a 2-cm right lateral defect (Fig. 3). After an uneventful postoperative course, the patient was discharged to a nursing facility on hospital day 31.

Fig. 3.

Intraoperative photograph shows the bovine pericardial patch (dashes) used to close the large pericardial defect.

Comment

Pericardial rupture with cardiac herniation through the defect (cardiac luxation) is rare and has a high mortality rate. Typically, rupture occurs in the left pleuropericardium, but diaphragmatic and right pleuropericardial tears have also been reported.¹ Hemodynamic status can be compromised when torsion around the pulmonary veins restricts vascular flow; however, stability may be preserved in right-sided tears.

This injury should be suspected in patients who have substantial chest, spinal, abdominal, and extremity trauma. The clinical signs, resembling those of tamponade, include fluctuating hemodynamic values and a splashing millwheel murmur.²

Cardiac luxation (from the Latin luxare, to displace or force out of position) occurs in up to half of patients who have traumatic pericardial defects.³ Diagnosis is most often made intraoperatively or at autopsy. Chest radiography is useful for screening; and TEE, to exclude other injuries. Sequential evaluation over time is recommended because luxation can be intermittent. Computed tomography, the most sensitive diagnostic method, can detect subtle findings, such as pneumopericardium, pericardial dimpling or discontinuity, abnormalities of the cardiac silhouette, and findings consistent with tamponade.³

Timely thoracoscopy should be performed if cardiac luxation is suspected, and open repair undertaken upon confirmation. Small defects can be primarily closed with nonabsorbable sutures; large defects, such as those in our patient, may need to be closed with prosthetic patches.²