Case Report

Transdiaphragmatic repositioning of the heart in the setting of emergency laparotomy after blunt trauma

Abstract

Cardiac luxation after blunt trauma is a Rare condition that carries a high mortality rate. We report a case of a left pericardial rupture with partial dislocation of the heart into the left Pleural cavity and cardiac strangulation in a polytraumatized patient after a severe motor vehicle accident. This case is of special interest because the patient not only had cardiovascular compromise but was also actually in cardiac arrest and being resuscitated when an emergency repositioning of the heart through the diaphragm in the setting of Damage control laparotomy restored circulation. This report stresses the need for a high index of suspicion for accurate early diagnosis of pericardial rupture.

Traumatic rupture of the pericardium represents a serious injury with a reported incidence of 0.3% to 0.5% after blunt chest trauma [1-3]. However, the true incidence may be underestimated because even today, many patients do not arrive at the hospital alive. motor vehicle accidents are the most common source of injury according to the 2 largest series reported in the literature [3,4]. More than 50% of all pericardial ruptures are located anterior or posterior to the phrenic nerve on the left side of the heart. In up to 28% of all cases, luxation of the heart follows pericardial rupture [3,4]. With luxation of the heart, mortality of patients increases to 67% [3]. Until 1939, all cases of traumatic rupture of the pericardium but 4 [5,6] were diagnosed accidentally in postmortem studies [7]. Even with modern imaging modalities, diagnosis of pericardial rupture remains difficult, and most of the cases reported in the literature were incidental findings at emergency thoracotomy or laparotomy in patients with multiple trauma. We present a case of luxatio cordis where the diagnosis was missed by the radiologist on the original computer tomography (CT) scan.

A 47-year-old man was involved in a frontal motor vehicle crash. A physician-staffed helicopter was dispatched to the scene. The patient was trapped in his car, and extrication was difficult. The emergency physician found a polytraumatized (craniocerebral, thoracic, abdominal

trauma, pelvic fracture, femoral fracture, fracture of the olecranon, and crural fracture) patient with Glasgow Coma Score 3, gasping respiration, and barely palpable pulse. Initial blood pressure was 120/70 mm Hg with a pulse of

140. Suctioning, tracheal intubation, and right-sided tube thoracostomy were performed. During air transport, the patient’s hemodynamic situation deteriorated in spite of aggressive fluid resuscitation. On arrival in the emergency department of our facility, the patient was in hypovolemic shock, and 10 units of Packed red blood cells were transfused immediately before transfer to the operating room. Focused abdominal sonography for trauma showed a minimal amount of free fluid, and bilateral serial rib fractures were diagnosed on the chest radiograph. The posterior displacement of the heart visible on the CT scan was attributed to a large left pneumothorax (Fig. 1). Suspected intra-abdominal bleeding due to laceration of the liver and mesenterium led to emergency laparotomy. In spite of the fact that the bleeding from Liver laceration was quickly controlled, the patient’s hemodynamic situation rapidly deteriorated and cardiac arrest occurred. The chief thoracic surgeon who had been called to the operating room to help the operating team immediately suspected cardiac luxation on the CT scan and performed an emergency pericardiotomy from the existing laparotomy. Meanwhile, cardiopulmonary resuscitation was performed for approximately 3 minutes. After repositioning

Fig. 1 The CT scan showing the large left pneumothorax and posterior displacement of the heart.

0735-6757/$ – see front matter (C) 2009

1024.e2 Case Report

of the heart that was partially dislocated into the left pleural cavity through a 10-cm-long pericardial rent, circulation was restored. Laparotomy was closed and a Left thoracotomy performed, which revealed a pericardial tear located poster- ior to the phrenic nerve running in a vertical direction from the base toward the apex (Fig. 2). The heart showed signs of severe contusion and atrial fibrillation. Sutured epicardial electrodes were placed by the consulted heart surgeon, and the pericardium was closed with a Gore-Tex(R) patch using interrupted sutures. Damage control orthopedic surgery was limited to external fixation of the left femur and temporary elbow wound closure due to severe impairment of coagula- tion requiring massive transfusion of blood products. Unfortunately, patient outcome was limited by severe craniocerebral trauma in this case.

Rupture of the pericardium with luxation of the heart is a difficult diagnosis. It is frequently associated with other severe traumatic injuries such as pelvic fractures or internal abdominal lesions, which can mask clinical signs and symptoms. Clinical signs of cardiac herniation include loud heart sounds, splashing murmur (“bruit de moulin”) as described by Morel-Lavallee [6], deviation of apex beats and signs of elevated right venous pressure (jugular vein distension). electrocardiographic signs are nonspecific with alteration in repolarization, axis deviation, T-wave inversion, or acute bundle branch block. Especially in trauma patients, it seems to be difficult to establish the diagnosis by chest radiography because the signs, such as abnormal cardiac silhouette or pneumopericardium, are easily overlooked in the presence of traumatic abdominal and cerebral injuries. Emergency ultrasound and echocardiography are also of limited value for the detection of possible cardiac luxation. Transesophageal echocardiography may show a pericardial lesion but is rarely performed in an unstable polytrauma patient. The use of CT as a Diagnostic modality was first described by Place and Cavanaugh in 1995 [8]. In a recent publication, Leibecke et al [9] described dislodgment of the heart, entrapment of the left atrium and ventricle, and

Fig. 2 Pericardial tear.

pneumopericardium associated with pneumothorax as the most important CT findings in their study of 9 patients with pericardial rupture and cardiac luxation after blunt chest trauma or extended left pneumectomy. Sohn et al [10] reported a case where cardiac magnetic resonance imaging confirmed periCardiac rupture with cardiac herniation as suspected on CT.

Pericardial rupture with luxation of the heart is a rare but dramatic complication of blunt Thoracic trauma. A high index of suspicion is critical to facilitate early diagnosis.

Rainer Gumpert MD Department of Trauma Surgery Medical University of Graz 8036 Graz, Austria

Sylvia Archan MD

Department of Anesthesiology and Critical Care

Medical University of Graz 8036 Graz, Austria

E-mail address: [email protected]

Veronika Matzi MD

Department of Surgery Division of Thoracic and Hyperbaric Surgery

Medical University of Graz 8036 Graz, Austria

Freyja-Maria Smolle-Juttner MD

Department of Surgery Division of Thoracic and Hyperbaric Surgery

Medical University of Graz 8036 Graz, Austria

doi:10.1016/j.ajem.2008.12.033

References

1. Martin TD, et al. blunt cardiac rupture. J Trauma 1984;24(4):287-90.
2. Shorr RM, et al. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987;206(2):200-5.
3. Fulda G, et al. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989). J Trauma 1991;31(2):167-72

[discussion 172-3].

1. Clark DE, et al. Traumatic rupture of the pericardium. Surgery 1983;93

(4):495-503.

1. Stokes W. A case of probable dislocation of the heart from external violence. Edinb Med Surg J 1831;36:45-50.
2. Morel-Lavallee VAF. Rupture du pericarde; bruit de roue hydraulique; bruit de moulin. Gaz Med Paris, 1864. 19: p. 695-6, 729-30, 771-2.
3. Crynes SF, Hunter WC. Traumatic rupture of the pericardium. Arch Intern Med 1939;64:719-46.
4. Place RJ, Cavanaugh DG. Computed tomography to diagnose pericardial rupture. J Trauma 1995;38(5):822-3.
5. Leibecke T, et al. Posttraumatic and postoperative cardiac luxation: computed tomography findings in nine patients. J Trauma 2008;64(3): 721-6.
6. Sohn JH, et al. Case report: pericardial rupture and cardiac herniation after blunt trauma: a case diagnosed using cardiac MRI. Br J Radiol 2005;78(929):447-9.