Reduction of cardiac herniation following intrapericardial pneumonectomy with pleural perfusion of saline

Excerpt

A 53-year-old woman was diagnosed with cardiac herniation after a right intrapericardial pneumonectomy for lung cancer. A chest X-ray (Fig. 1a) and thoracic CT (Fig. 1c) revealed the heart rotated to the right hemithorax. CT venography demonstrated the distortion and stenosis of the great veins and occlusion of venous return (Fig. 1e, f). She presented severe hemodynamic instability. Review of the literature revealed that most cases survived via reoperation to reintroduce the heart into the pericardium, and an urgent measurement included returning to the lateral position with non-surgical side down and injecting air into the surgical hemithorax to reduce cardiac herniation. For this patient, a pleural perfusion of 2000 ml saline into the right hemithorax reduced herniation, and a backward rotation of the heart was performed (Fig. 1b, d). Vasopressor use was suspended immediately following the injection. It is believed that the increased pleural fluid provided buoyancy, and the increased volume and pressure prevented mediastinum flutter. The patient could have recovered from this conservative treatment; however, replacement of the superior vena cava (SVC) with a vascular prosthesis was performed secondary to SVC thrombosis. During the perioperative period of reoperation, the abundant pleural fluid preserved in the surgical hemithorax resulted in an uneventful recovery.

…