CHEST Guidelines-A-Young-Woman-With-Severe-Hypotension-After-Right-

A-Young-Woman-With-Severe-Hypotension-After-Right-

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A 33-year-old woman underwent a successful right lung lobectomy for adenocarcinoma, involving a partial pericardiectomy and reconstruction of the upper pulmonary vein. Post-surgery, she developed severe hypotension (59/30 mm Hg) and tachycardia despite stable intraoperative vitals. Arterial blood gases showed severe metabolic acidosis, and her condition did not improve with fluid resuscitation and norepinephrine. A point-of-care ultrasound indicated that her heart was not in its normal location, suggesting cardiac herniation, confirmed by a chest radiograph showing mediastinal shift.<br /><br />Cardiac herniation, a rare but life-threatening complication, occurs when the heart protrudes through a defect in the pericardium, possibly due to iatrogenic causes in this case. It led to torsion of her pulmonary artery, drastically affecting cardiac output and blood pressure. The patient's stable PaO2 ruled out a pulmonary embolism, directing suspicion toward cardiac herniation due to surgical manipulation.<br /><br />Emergency re-thoracotomy was performed, revealing right-sided cardiac herniation and torsional obstruction of the pulmonary artery. The heart was repositioned, and the pericardial defect was repaired with a patch, resulting in gradual circulatory improvement. Subsequent studies confirmed recovery of cardiac function.<br /><br />This case underscores the importance of quick diagnosis through tools like Transthoracic and Transesophageal Echocardiography (TEE) and the necessity of rapid surgical intervention for cardiac herniation post-pneumonectomy. Cardiac herniation is linked with high mortality without timely recognition and intervention, making prompt diagnosis and re-thoracotomy crucial. The report also notes that right-sided herniation can critically impact venous return and cardiac filling due to vessel torsion.

Keywords

cardiac herniation

lung lobectomy

adenocarcinoma

pericardiectomy

mediastinal shift

torsional obstruction

pulmonary artery

re-thoracotomy

echocardiography

surgical intervention