Case Report |
Corresponding author: Ivoslav Ivanov ( ivoslavivanov@gmail.com ) © 2023 Ivoslav Ivanov, Dimo Mitev, Rumen Filipov, Plamen Parvanov.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Ivanov I, Mitev D, Filipov R, Parvanov P (2023) Right-sided luxation of the heart caused by blunt traumatic pericardial rupture. Folia Medica 65(2): 331-335. https://doi.org/10.3897/folmed.65.e78431
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Cardiac luxation is a rare condition in cases of blunt thoracic trauma, yet it is quite fatal. We present a case of a 28-year-old man, admitted to the emergency room after a motorcycle accident in a hemodynamically unstable condition and radiographic presentation of multiple rib fractures, bilateral pneumothorax, pneumomediastinum, and significant dislocation of the heart to the right. After performing emergency bilateral tube thoracostomy and achieving hemodynamic stability, a CT scan was performed and the patient was diagnosed with pericardial rupture with right-sided luxation of the heart. An emergency sternotomy was performed with repositioning of the heart and pericardial reconstruction. In the postoperative period, suspicion of myocardial infarction was ruled out and the patient was discharged with persistent traumatic monoplegia of the left upper limb and Claude Bernard-Horner syndrome. An analysis of this very rare type of chest trauma has been made and the probable mechanism for its occurrence has been discussed.
blunt thoracic trauma, cardiac herniation, heart luxation, pericardial rupture
The heart is injured in an estimated 15% of cases of major blunt thoracic trauma.[
We present a case of a 28-year-old male with heart luxation due to an isolated right pericardium tear with a specific clinical presentation. The patient was brought to the emergency department after being hit by a car while driving a motorcycle. He was admitted to the ER in a state of shock with blood pressure measured to 90/59 mmHg and heart rate up to 130 beats per minute. On examination, breath sounds were absent on the left hemithorax, dramatically decreased in the right and subcutaneous emphysema was present around the chest. Glasgow Coma Scale score at admission was 12 points. Abdomen and limbs were found with no changes on physical examination and focused assessment with sonography in trauma (FAST) exam showed no free fluid in the abdomen but suspicious signs of pericardial air were found. Therefore, a chest radiograph was done and showed tension left-sided pneumothorax with significant dislocation of the heart in the right, partial right-sided pneumothorax and multiple bilateral rib fractures (Fig.
Additional paraclinical studies showed depression of the ST segment from the ECG, with elevated laboratory values of cardiac enzymes.
The neurological clinical study diagnosed a post-traumatic lesion of the left brachial plexus with plegia of the left arm based on intramedullary traumatic changes in the neck area and Claude Bernard-Horner syndrome. A secondary larger thoracostomy tube (34 Ch) was inserted in the left pleural space because of the persistent pneumothorax and after initial resuscitation, preparations were made for major cardiothoracic intervention.
An approach via midline sternotomy was used and the following traumatic injuries were identified: large pericardial rupture located from the level of the diaphragm to the hilum of the right lung with a length of 8.5–9 cm (Fig.
Manual repositioning of the heart was performed and subsequently, the pericardial defect was repaired with its tissues and closure of the right pleural tears. A total of 4 silk (size 0) stitches were applied, the first being X-shaped (Fig.
After cardiac repositioning, ECG changes suspicious for myocardial infarction were no longer recorded and cardiac enzymes were in normal ranges from laboratory studies. Areas of pulmonary contusion were identified in both lungs on postoperative CT (Figs
Chest radiograph showing tension pneumothorax on the left with a complete collapse of the lung, partial pneumothorax on the right. Significant dislocation of the heart to the right.
A. CT of the thorax. Heart, aortic arch and main vessels positioned in the right thoracic half. B. Pneumomediastinum along the course of the descending part of the aorta. Subcutaneous emphysema on the left axillary area. Minimal pleural effusions bilaterally.
Chest radiograph: normal positioning of heart and major vessels, post-traumatic pulmonary contusion areas in both lungs.
Isolated pericardial ruptures without damage to the myocardium or valvular apparatus are very rare in clinical practice.[
In cases of pneumothorax, after lung expansion by tube thoracostomy, pericardial rupture with heart dislocation to the left or, less frequently, to the right may go undetected in the initial hours of arrival.[
Lindenmann et al. and Wang et al., reported similar cases but compared to our technique they used left thoracotomy as an operative approach and prosthetic material was used to repair the pericardial rupture.[
The intimate mechanism of pericardial rupture in blunt thoracic trauma is not sufficiently clarified. Factors such as the moment of inertia, hydrodynamic impact, elasticity, and resistance of different tissues are discussed.[
Pericardial rupture with cardiac herniation is a rare injury seen after blunt thoracic trauma. A high index of suspicion is required in cases of rapid deceleration mechanisms in trauma that present with hypotension and signs of heart dislocation with hemodynamic instability. If the injury is recognized in time, treatment is simple and effective. The shortened time for surgical intervention with manual repositioning of the heart is a major factor for a favorable outcome.