- Email: [email protected]
Traumatic rupture of the pericardium with dislocation of the heart
Injury (1984) 16, 123-125
PrintedinGreatBritain
123
Traumatic rupture of the pericardium with dislocation of the heart R. P. Clifford Department of Orthopaedics and Trauma, University Hospital, Nottingham K. S. Gill Department of Thoracic Surgery, City Hospital, Nottingham
Summary Isolated rupture of the parietal pericardium with herniation of the heart may occur following closed injury of the chest. Such a case is presented here. Clinical suspicion should be aroused by the presence of low cardiac output with localizing signs of cardiac displacement. X-ray films of the chest may reveal important clues and provide an indication for cardiac angiography, which may be diagnostic.
INTRODUCTION PERICARDIAL r u p t u r e is well recognized following closed injury o f the chest. This is usually p a r t o f m o r e extensive d a m a g e to the h e a r t a n d g r e a t vessels, b u t o c c a s i o n a l l y the d a m a g e is confined to the p e r i c a r d i u m ( P a r m l e y et al., 1958).
CASE REPORT A 51-year-old man was admitted to hospital following a fall from a height of 18m. On arrival at the Accident and Emergency Department he was conscious and alert. He had a pulse rate of 60/min and a blood pi'essure of 130/100. The only obvious injuries noted on admission were a fracture-dislocation of the right hip, a fracture of the right 3rd rib and a wound of the chin. While awaiting transfer to the operating theatre for reduction of the hip his condition deteriorated and his blood pressure fell to 85/50. Occult haemorrhage was suspected but there was no clinical evidence of intra-abdominal or intrathoracic bleeding. An X-ray film of the chest (Fig. l) revealed no evidence of haemothorax but the heart was unusually well outlined, with the apex extending well over to the left side of the chest. The significance of this was not realized at the time. The patient's condition improved following transfusion and he received a general anaesthetic for closed reduction of the hip without further complication. Overnight he once again became hypotensive and a second X-ray film of the chest revealed a left-sided haemothorax. One litre of blood was removed by a drain. Despite further transfusions his blood pressure remained low, but with no evidence of continued bleeding from the chest or elsewhere. The central venous pressure (CVP) remained normal and there was no evidence of cardiac tamponade. Electrocardiography showed sinus rhythm with a low voltage tracing over the standard leads and 180 ° axis deviation with no R-wave progression across the chest leads. An echocardiogram and cardiac fluoroscopy confirmed the radiological and ECG evidence that the heart was displaced to the left. Urgent cardiac angiography was performed. The superior and inferior venae cavae and the right
border of the heart were shown to be displaced to the left (Fig. 2). Films later in the series revealed an indentation of the superior border of the main pulmonary trunk immediately distal to the pulmonary valve (Fig. 3). There was no evidence of more extensive cardiac damage, aortic or vena caval haemorrhage. The obvious displacement of the heart and the extraluminal obstruction of the pulmonary trunk suggested the rare diagnosis of cardiac dislocation through a pericardial rupture. Immediate thoracotomy confirmed the diagnosis. The heart was seen to be herniated through a tear in the pericardium, the free edge of which was strangulating the main pulmonary trunk (Fig. 4). The left lung and the myocardium of the left ventricle beneath the constriction ring were contused. The pericardium was excised and the chest was closed over two drains. A Swan-Ganz catheter was inserted to allow detailed recording of the haemodynamic state in the postoperative period. Despite continued intermittent positive-pressure ventilation (IPPV) with positive end expiratory pressure (PEEP) and
Fig. 1. Chest X-ray film showing unusually clear cardiac silhouette extending well over to the left side of the chest.
124
Injury: the British Journal of Accident Surgery (1984) Vol. 16/No. 2
Fig. 2. Cardiac angiogram showing the right border of the heart (arrowed) displaced to the left.
Fig. 4. Photograph taken during thoracotomy showing the heart devoid of its pericardium revealing a constriction ring across the base of the heart.
Fig. 3. Cardiac angiogram showing a constriction in the base of the pulmonary artery (arrowed). inotropic circulatory support, the patient's condition deteriorated. There was difficulty in maintaining cardiac output and pulmonary capillary wedge pressure (PCWP) and he died 24 hours later. At post mortem, death was confirmed as being due to cardiorespiratory failure. Pulmonary oedema with contused lung and myocardium was present and, in addition, there was a 2-cm intimal tear of the root of the aorta with no sign of dissection. DISCUSSION
Pericardial tears may occur more commonly than is clinically suspected because, unless they are accompanied by cardiovascular embarrassment, attention may be focused on more obvious injuries. Clinical features depend on the anatomical site of rupture. Herniation of the abdominal viscera into the pericardial sac may follow rupture of the diaphragmatic pericardium (Crawshaw, 1952; Herman and Goldstein, 1965). Pleuropericardial tears may result in haemorrhage from a torn pericardiophrenic artery (Levy, 1937). If the pleuropericardial tear ~s large, the heart may escape into the pleural cavity.
Such displacement of the heart through a deficiency of the pleuropericardium has been more frequently'described following pneumonectomy and partial pericardiectomy for malignant disease of the lung (Allison, 1946; Patel et al., 1973). However, the condition has been documented following traumatic pleuropericardial rupture, variously described as a cardiac dislocation (King and Sapsford, 1978), luxation (Mattila et al., 1975) and herniation (Liedke and DeMuth, 1973). Displacement may occur at the time of injury, or its presentation may be delayed, when the heart 'squeezes' out through the pericardial tear during systole (Borrie and Lichter, 1974). The condition usually occurs on the left but dislocation to the right has been described (King and Sapsford, 1978). Diagnosis of pericardial rupture with cardiac dislocation may be difficult. The presence of hypotension may be attributed to other injuries. The most reliable signs are related to the abnormal position of the heart. The apex beat may be displaced and the heart sounds faint and associated with a murmur. Electrocardiography may provide further evidence of cardiac displacement, possibly in association with ischaemic changes. A plain X-ray film of the chest provides the main clues. The cardiac shadow is in an unusual position; if the heart is displaced to the left, the right border of the vertebral column is unusually clear (Fig. 5). The heart's silhouette may be clearly outlined, particularly with air in the pericardial sac from an associated pneumothorax (Reynolds and Davis, 1966).
Clifford and Gill: Traumatic dislocation of the heart
125
Fig. 5. Chest X-ray film showing an unusually clear right vertebral margin.
Operation is urgently required in the critically ill patient with a low cardiac output and an X-ray film which shows the above features. If the patient's condition will allow, however, further investigations may be helpful. Echocardiography and cardiac fluoroscopy are not invasive techniques which may confirm cardiac displacement. Cardiac angiography provides further information and should be diagnostic. The extent of cardiac displacement will be evident and constriction of the heart or a great vessel by the torn edge of the pericardium will be seen. Further important information will be provided about the possibilities of haemorrhage or more extensive damage to the heart or great vessels. In our case, we did not immediately recognize the significance of the abnormal cardiac shadow on the original chest film. Diagnostic angiography was only performed after a period of unaccountable hypotension during which the myocardium presumably underwent considerable damage from the strangulating edge of the pericardium. Early angiography, as indicated by the abnormal X-ray appearance and original hypotensive • pisode, would have resulted in early diagnosis and may have saved this patient's life. CONCLUSION
Traumatic rupture of the pericardium with dislocation of the heart is a rare event. The suggestion of cardiac displacement following injury of the chest should alert the clinician to its possibility. If this condition is suspected, cardiac angiography may be diagnostic. Thoracotomy should be performed urgently and the heart restored to its rightful position, together with repair or excision of the pericardium. Acknowledgements
The authors wish to thank Mr W. E. Morgan FRCS, Consultant Thoracic Surgeon, and Dr A. Byrne FFA,
Consultant Anaesthetist, for allowing us to document this case and for their help in preparing this paper.
REFERENCES
Allison P. R. (1946) Intrapericardial approach to the lung root in the treatment of bronchial carcinoma by dissection pneumonectomy. J. Thorac. Surg. 15, 99. Borrie J. and Lichter I. (1974) Pericardial rupture from blunt chest trauma. Thorax 29, 329. Crawshaw G. R. (1952) Herniation of the stomach, transverse colon and a portion of the jejunum into the pericardium. Br. J. Surg. 39, 364. Herman P. G. and Goldstein J. E. (1965) Traumatic interpericardial diaphragmatic hernia, Br. J. Radiol. 38, 631. King J. B. and Sapsford R. N. (1978) Acute rupture of the pericardium with delayed dislocation of the heart: a case report. Injury 9 303. Levy M. L. (1937) Non-penetrating wound of the heart: injury to the pericardium and left pericardiophrenic artery with near fatal haemorrhage. N Y State J, Med. 37, 1442. Liedke A. J. and DeMuth W. E. (1973) Non-penetrating cardiac injuries; a collective review. Am. Heart J. 86, 687. Parmley F. F., Manion W. C. and Mattingley J. W. (t958) Non-penetrating traumatic injury to the heart. Circulation 18, 371. Patel D. R., Shrivastav R. and Sabiety A. M. (1973) Cardiac torsion following intrapericardial pneumonectomy. J. Thorac, Cardiovasc. Surg. 65, 626. Mattila S., Heikki S. and Ketonen P. (1975) Traumatic rupture of the pericardium with luxation of the heart: a case report and review of the literature. J. Thorac. Cardiovasc. Surg. 70, 495. Reynolds J. and Davis J. T. (1966) Injuries of the chest wall, pleura, pericardium, lungs, bronchi and oesophagus. Radiol. Clin. North Am. 4, 383. Paper accepted 22 December 1983.
Requests for reprints should be addressed to: Mr R. P. Clifford, FRCS,Senior Registrar, Dept. of Orthopaedics, Southampton General Hospital,
Tremona Road, Southampton.
PrintedinGreatBritain
123
Traumatic rupture of the pericardium with dislocation of the heart R. P. Clifford Department of Orthopaedics and Trauma, University Hospital, Nottingham K. S. Gill Department of Thoracic Surgery, City Hospital, Nottingham
Summary Isolated rupture of the parietal pericardium with herniation of the heart may occur following closed injury of the chest. Such a case is presented here. Clinical suspicion should be aroused by the presence of low cardiac output with localizing signs of cardiac displacement. X-ray films of the chest may reveal important clues and provide an indication for cardiac angiography, which may be diagnostic.
INTRODUCTION PERICARDIAL r u p t u r e is well recognized following closed injury o f the chest. This is usually p a r t o f m o r e extensive d a m a g e to the h e a r t a n d g r e a t vessels, b u t o c c a s i o n a l l y the d a m a g e is confined to the p e r i c a r d i u m ( P a r m l e y et al., 1958).
CASE REPORT A 51-year-old man was admitted to hospital following a fall from a height of 18m. On arrival at the Accident and Emergency Department he was conscious and alert. He had a pulse rate of 60/min and a blood pi'essure of 130/100. The only obvious injuries noted on admission were a fracture-dislocation of the right hip, a fracture of the right 3rd rib and a wound of the chin. While awaiting transfer to the operating theatre for reduction of the hip his condition deteriorated and his blood pressure fell to 85/50. Occult haemorrhage was suspected but there was no clinical evidence of intra-abdominal or intrathoracic bleeding. An X-ray film of the chest (Fig. l) revealed no evidence of haemothorax but the heart was unusually well outlined, with the apex extending well over to the left side of the chest. The significance of this was not realized at the time. The patient's condition improved following transfusion and he received a general anaesthetic for closed reduction of the hip without further complication. Overnight he once again became hypotensive and a second X-ray film of the chest revealed a left-sided haemothorax. One litre of blood was removed by a drain. Despite further transfusions his blood pressure remained low, but with no evidence of continued bleeding from the chest or elsewhere. The central venous pressure (CVP) remained normal and there was no evidence of cardiac tamponade. Electrocardiography showed sinus rhythm with a low voltage tracing over the standard leads and 180 ° axis deviation with no R-wave progression across the chest leads. An echocardiogram and cardiac fluoroscopy confirmed the radiological and ECG evidence that the heart was displaced to the left. Urgent cardiac angiography was performed. The superior and inferior venae cavae and the right
border of the heart were shown to be displaced to the left (Fig. 2). Films later in the series revealed an indentation of the superior border of the main pulmonary trunk immediately distal to the pulmonary valve (Fig. 3). There was no evidence of more extensive cardiac damage, aortic or vena caval haemorrhage. The obvious displacement of the heart and the extraluminal obstruction of the pulmonary trunk suggested the rare diagnosis of cardiac dislocation through a pericardial rupture. Immediate thoracotomy confirmed the diagnosis. The heart was seen to be herniated through a tear in the pericardium, the free edge of which was strangulating the main pulmonary trunk (Fig. 4). The left lung and the myocardium of the left ventricle beneath the constriction ring were contused. The pericardium was excised and the chest was closed over two drains. A Swan-Ganz catheter was inserted to allow detailed recording of the haemodynamic state in the postoperative period. Despite continued intermittent positive-pressure ventilation (IPPV) with positive end expiratory pressure (PEEP) and
Fig. 1. Chest X-ray film showing unusually clear cardiac silhouette extending well over to the left side of the chest.
124
Injury: the British Journal of Accident Surgery (1984) Vol. 16/No. 2
Fig. 2. Cardiac angiogram showing the right border of the heart (arrowed) displaced to the left.
Fig. 4. Photograph taken during thoracotomy showing the heart devoid of its pericardium revealing a constriction ring across the base of the heart.
Fig. 3. Cardiac angiogram showing a constriction in the base of the pulmonary artery (arrowed). inotropic circulatory support, the patient's condition deteriorated. There was difficulty in maintaining cardiac output and pulmonary capillary wedge pressure (PCWP) and he died 24 hours later. At post mortem, death was confirmed as being due to cardiorespiratory failure. Pulmonary oedema with contused lung and myocardium was present and, in addition, there was a 2-cm intimal tear of the root of the aorta with no sign of dissection. DISCUSSION
Pericardial tears may occur more commonly than is clinically suspected because, unless they are accompanied by cardiovascular embarrassment, attention may be focused on more obvious injuries. Clinical features depend on the anatomical site of rupture. Herniation of the abdominal viscera into the pericardial sac may follow rupture of the diaphragmatic pericardium (Crawshaw, 1952; Herman and Goldstein, 1965). Pleuropericardial tears may result in haemorrhage from a torn pericardiophrenic artery (Levy, 1937). If the pleuropericardial tear ~s large, the heart may escape into the pleural cavity.
Such displacement of the heart through a deficiency of the pleuropericardium has been more frequently'described following pneumonectomy and partial pericardiectomy for malignant disease of the lung (Allison, 1946; Patel et al., 1973). However, the condition has been documented following traumatic pleuropericardial rupture, variously described as a cardiac dislocation (King and Sapsford, 1978), luxation (Mattila et al., 1975) and herniation (Liedke and DeMuth, 1973). Displacement may occur at the time of injury, or its presentation may be delayed, when the heart 'squeezes' out through the pericardial tear during systole (Borrie and Lichter, 1974). The condition usually occurs on the left but dislocation to the right has been described (King and Sapsford, 1978). Diagnosis of pericardial rupture with cardiac dislocation may be difficult. The presence of hypotension may be attributed to other injuries. The most reliable signs are related to the abnormal position of the heart. The apex beat may be displaced and the heart sounds faint and associated with a murmur. Electrocardiography may provide further evidence of cardiac displacement, possibly in association with ischaemic changes. A plain X-ray film of the chest provides the main clues. The cardiac shadow is in an unusual position; if the heart is displaced to the left, the right border of the vertebral column is unusually clear (Fig. 5). The heart's silhouette may be clearly outlined, particularly with air in the pericardial sac from an associated pneumothorax (Reynolds and Davis, 1966).
Clifford and Gill: Traumatic dislocation of the heart
125
Fig. 5. Chest X-ray film showing an unusually clear right vertebral margin.
Operation is urgently required in the critically ill patient with a low cardiac output and an X-ray film which shows the above features. If the patient's condition will allow, however, further investigations may be helpful. Echocardiography and cardiac fluoroscopy are not invasive techniques which may confirm cardiac displacement. Cardiac angiography provides further information and should be diagnostic. The extent of cardiac displacement will be evident and constriction of the heart or a great vessel by the torn edge of the pericardium will be seen. Further important information will be provided about the possibilities of haemorrhage or more extensive damage to the heart or great vessels. In our case, we did not immediately recognize the significance of the abnormal cardiac shadow on the original chest film. Diagnostic angiography was only performed after a period of unaccountable hypotension during which the myocardium presumably underwent considerable damage from the strangulating edge of the pericardium. Early angiography, as indicated by the abnormal X-ray appearance and original hypotensive • pisode, would have resulted in early diagnosis and may have saved this patient's life. CONCLUSION
Traumatic rupture of the pericardium with dislocation of the heart is a rare event. The suggestion of cardiac displacement following injury of the chest should alert the clinician to its possibility. If this condition is suspected, cardiac angiography may be diagnostic. Thoracotomy should be performed urgently and the heart restored to its rightful position, together with repair or excision of the pericardium. Acknowledgements
The authors wish to thank Mr W. E. Morgan FRCS, Consultant Thoracic Surgeon, and Dr A. Byrne FFA,
Consultant Anaesthetist, for allowing us to document this case and for their help in preparing this paper.
REFERENCES
Allison P. R. (1946) Intrapericardial approach to the lung root in the treatment of bronchial carcinoma by dissection pneumonectomy. J. Thorac. Surg. 15, 99. Borrie J. and Lichter I. (1974) Pericardial rupture from blunt chest trauma. Thorax 29, 329. Crawshaw G. R. (1952) Herniation of the stomach, transverse colon and a portion of the jejunum into the pericardium. Br. J. Surg. 39, 364. Herman P. G. and Goldstein J. E. (1965) Traumatic interpericardial diaphragmatic hernia, Br. J. Radiol. 38, 631. King J. B. and Sapsford R. N. (1978) Acute rupture of the pericardium with delayed dislocation of the heart: a case report. Injury 9 303. Levy M. L. (1937) Non-penetrating wound of the heart: injury to the pericardium and left pericardiophrenic artery with near fatal haemorrhage. N Y State J, Med. 37, 1442. Liedke A. J. and DeMuth W. E. (1973) Non-penetrating cardiac injuries; a collective review. Am. Heart J. 86, 687. Parmley F. F., Manion W. C. and Mattingley J. W. (t958) Non-penetrating traumatic injury to the heart. Circulation 18, 371. Patel D. R., Shrivastav R. and Sabiety A. M. (1973) Cardiac torsion following intrapericardial pneumonectomy. J. Thorac, Cardiovasc. Surg. 65, 626. Mattila S., Heikki S. and Ketonen P. (1975) Traumatic rupture of the pericardium with luxation of the heart: a case report and review of the literature. J. Thorac. Cardiovasc. Surg. 70, 495. Reynolds J. and Davis J. T. (1966) Injuries of the chest wall, pleura, pericardium, lungs, bronchi and oesophagus. Radiol. Clin. North Am. 4, 383. Paper accepted 22 December 1983.
Requests for reprints should be addressed to: Mr R. P. Clifford, FRCS,Senior Registrar, Dept. of Orthopaedics, Southampton General Hospital,
Tremona Road, Southampton.