Blunt Trauma–Induced Pericardial Tamponade After Video-Assisted Thoracoscopic Surgery

Accepted Manuscript Blunt trauma-induced pericardial tamponade after video-assisted thoracoscopic surgery Xuebing Chen, MD, Qi Miao, MD, Yangeng Yu, MD, Fu Zhang, MD, Leping Sun, MD, Yunle Meng, MD, Huijun Wang, MD, Dongri Li, MD PII:

S0003-4975(18)31703-X

DOI:

https://doi.org/10.1016/j.athoracsur.2018.10.046

Reference:

ATS 32166

To appear in:

The Annals of Thoracic Surgery

Received Date: 28 August 2018 Revised Date:

9 October 2018

Accepted Date: 13 October 2018

Please cite this article as: Chen X, Miao Q, Yu Y, Zhang F, Sun L, Meng Y, Wang H, Li D, Blunt traumainduced pericardial tamponade after video-assisted thoracoscopic surgery, The Annals of Thoracic Surgery (2018), doi: https://doi.org/10.1016/j.athoracsur.2018.10.046. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Blunt trauma-induced pericardial tamponade after video-assisted thoracoscopic surgery Running Head: Blunt cardiac injury after VATS

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Xuebing Chen, MD1, Qi Miao, MD1, Yangeng Yu, MD2, Fu Zhang, MD2, Leping Sun, MD1, Yunle Meng, MD1, Huijun Wang, MD1*, Dongri Li, MD1*

School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China

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Key laboratory of forensic pathology, ministry of public security, Guangzhou 510515, China

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*Corresponding author

Dongri Li, School of Forensic Medicine, Southern Medical University, 1023# South Shatai Rd.,

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Guangzhou 510515, China, E-mail address:[email protected]

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ACCEPTED MANUSCRIPT Abstract We report a case of blunt cardiac injury and pericardial tamponade following video-assisted thoracoscopic surgery (VATS) in a lung cancer patient with hypertension and cardiac hypertrophy.

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Anatomical findings included massive hemorrhage in the pericardium, cardiac hypertrophy, and a superficial contusion with a ruptured blood vessel on the epicardium at the lateral wall of the left ventricle. The patient died of pericardial tamponade due to blunt trauma from the tip of the

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thoracoscopic instrument. This case suggests that detailed assessment of the cardiovascular system,

postoperative conditions are important.

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especially cardiac hypertrophy, careful preparation before surgery and careful monitoring of

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Key words: blunt trauma; pericardial tamponade; video-assisted thoracoscopic surgery; lung cancer

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ACCEPTED MANUSCRIPT Video-assisted thoracoscopic surgery (VATS) has become a type of minimally invasive technology that is widely used around the world. Because of its characteristics including a small incision, decreased perioperative blood loss, a quick postoperative recovery, and little influence on

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lung function and immune responses, VATS has become the main surgical treatment for early lung cancer (1). However, postoperative complications of VATS still affect patient prognosis. In 2008, Imperatori et al.(2) published data on their experience using VATS and related complications; the

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most common complications were a prolonged postoperative air leak (4.7%) followed by bleeding

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(1.5%) and wound infection (0.9%). However, no reports of VATS complicated with cardiac injury are currently available.

A 55-year-old man was admitted to the hospital because of a ground-glass nodule in the left upper lung for more than two weeks. The left upper lung mass was identified on positron emission

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tomography/computed tomography (PET/CT). The diameter of the tumor in the left upper posterior segment was approximately 2.5 cm and might be lung adenocarcinoma; the left lower lung mass was approximately 0.5 cm in diameter, and the mediastinal lymph nodes in the hilum were enlarged. After

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one week of preparation, radical resection of lung cancer in the left upper lung and wedge resection of

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the left lower lung were performed via VATS. The tumor in the left upper posterior segment was removed with Ethicon4.5 (Ethicon Endo-Surgery Industries, Cincinnati, OH). The left lower lung mass was removed with a wedge measuring >2 cm, and a sample was frozen for further pathological analysis. The results indicated that the left lower lung mass was lung adenocarcinoma with infiltrating carcinomatosis. No tumor cells were found in the margins of the residual tissue. The patient’s postoperative vital signs were stable, and he reported no particular discomfort. After the fifth postoperative day when the patient underwen B-ultrasound, his condition suddenly deteriorated 3

ACCEPTED MANUSCRIPT suddenly. Resuscitation efforts were unsuccessful, and the patient was declared dead. Medicolegal autopsy was performed on the next day. The findings showed that the patient was 173 cm in height and 59 kg in weight. On external examination, no truma was visible except for the

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operative incision. On internal examination, no histopathological changes, such as bleeding or infection, were found in the lung tissue at the surgical site. The pericardium was intact, and the pericardial cavity contained approximately 280 ml of hemorrhagic fluid with a 120-g blood clot (Fig.

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1A). The heart was hypertrophic (420 g) (3). A superficial contusion was observed at the lateral wall of

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the left ventricle approximately 8.5 cm from the apex. The size of the lesion was 2.0 cm×1.3 cm, and the ruptured blood vessel was the left marginal branch (Fig. 1B). The left coronary artery and right coronary artery were thickened, and atherosclerotic plaques had formed starting at the first 0.5-1.0 cm of these arteries. The lumen stenosis was 25%-50%. Approximately 550 ml of pink fluid and 370 ml of

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serous effusion were found in the left and right pleural cavities, respectively, and no clots were identified. Histopathological examination showed a continuous rupture of epicardial tissue at the lateral wall of the left ventricle, a ruptured blood vessel with dissection (Fig. 2A, 2B, and 2C), and

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necrosis, exudation, inflammatory cell infiltration, capillary proliferation, and fibroblast infiltration

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(Fig. 2D) in the perivascular tissue. The walls of the splenic arterioles were thickened and exhibited hyalinization, and some renal arterioles were thickened and showed onion skin-like changes. The shape of the injury matched the tip of the thoracoscopic instrument (Fig. 1C).The patient died of pericardial tamponade due to blunt trauma from the tip of the thoracoscopic instrument. Comment VATS has become a type of minimally invasive technology that is widely used around the world. However, VATS-associated postoperative complications still affect patient prognosis. Complication 4

ACCEPTED MANUSCRIPT rates following VATS lobectomy for lung cancer range from 6% to 34.2%, and the mortality rate ranges from 0.6% to 1.3%(4). The risk factors for complications after VATS include sex, age, history of smoking, other diseases (such as hypertension, heart disease, and diabetes), preoperative pulmonary

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function, operative time, intraoperative bleeding volume and the scope of lung resection (5). However, no reports of blunt cardiac injury following VATS lobectomy for lung cancer are currently available. Blunt cardiac injuries are common after traffic accidents, high falls or crush injuries. The symptoms

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and signs of blunt cardiac injury are often nonspecific and hidden, including mild palpitations or pain

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in the precordial area; which are often attributed to musculoskeletal damage and are easily masked by other injuries or diseases, leading to a delayed or easily missed diagnosis; thus, the mortality associated with these types of injuries is extremely high (6). A patient with heart disease (such as previous myocardial infarction, hypertension, a fatty heart, or cardiomyopathy) typically exhibits

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decreased systolic and diastolic function of the heart and a limited range of chest movement; consequently, blunt cardiac trauma is likely to occur when external forces are applied (7). The patient exhibited no trauma during physical examination after admission or after surgery;

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therefore, the possibility of intraoperative trauma was considered. Pathological changes, including

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tissue necrosis, inflammatory cell infiltration, capillary proliferation, and fibroblast infiltration and others, were found at the site of cardiac injury. According to the state of healing (8), the cardiac injury occurred approximately one week prior. Considering the shape, size and location of the cardiac contusion, only the tip of the thoracoscopic stapler used during VATS matched the characteristics of the injury. An improper surgical technique was an important factor in this outcome, but hypertension and cardiac hypertrophy are also important factors that should be noted. This case report suggests that the cardiovascular system, especially cardiac hypertrophy, must be 5

ACCEPTED MANUSCRIPT extensively evaluated before and after surgery, surgery must be carefully performed. Vital signs and oxygen saturation, especially chest discomfort and pleuritic pain, should be monitored continuously in the postoperative period. Fluoroscopy or another type of imaging, such as echocardiography or

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computer tomography (CT), should be performed timely to examine cardiac tamponade.

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thoracoscopic surgery (vats). Int J Surg;6 Suppl 1:S78-81.

Molina DK, Dimaio VJM. (2011) Normal organ weights in men. American Journal of Forensic

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Sandri A, Papagiannopoulos K, Milton R et al. (2015) Major morbidity after video-assisted

thoracic surgery lung resections: A comparison between the european society of thoracic surgeons

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definition and the thoracic morbidity and mortality system. J Thorac Dis;7(7):1174-1180. Wang S, Li X, Li Y et al. (2017) The long-term impact of postoperative pulmonary complications

after video-assisted thoracic surgery lobectomy for lung cancer. J Thorac Dis;9(12):5143-5152. Kanchan T, Menezes RG, Acharya PB, Monteiro FN. (2012) Blunt trauma to the chest--a case of

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delayed cardiac rupture. J Forensic Leg Med;19(1):46-47. 7.

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Yu TS, Ling Y, Guan DW. (2013) [progress in myofibroblast and its application in forensic

medicine]. Fa Yi Xue Za Zhi;29(2):140-143.

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Figure legends Figure 1. A, Hemorrhagic fluid with blood clots was observed in the pericardial cavity. B, The

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contusion at the lateral wall of the left ventricle is shown by the arrow. C, Characteristics of the contusion at the lateral wall of the left ventricle matches the tip of the thoracoscopic stapler.

Figure 2 The left ventricular wall contusionwas stained with hematoxylin and eosin (HE) (A, HE×50)

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and Masson’s trichrome (B, Masson×50); C, Vascular dissection is indicated by the arrowhead in the

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section stained with Masson’s trichrome (C,Masson×100); D, Inflammatory cell and fibroblast

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infiltration and capillary hyperplasia are visible below the ruptured vessel (D, HE×100).

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