A rare and life-threatening complication following lung removal surgery – cardiac herniation – was successfully addressed in a 65-year-old man thanks to rapid diagnosis using transesophageal echocardiography (TEE), according to a case report highlighting the critical role of advanced imaging in emergency surgical situations.
The patient underwent a right intrapericardial pneumonectomy at an unspecified hospital, a procedure to remove the right lung due to cancer invading the hilum, the region where major blood vessels and airways enter the lung. He had previously undergone induction targeted therapy. While the initial stages of the surgery, including extubation and stabilization of vital signs, were successful, a sudden and dramatic drop in blood pressure and loss of consciousness occurred as the patient was being prepared for discharge from the operating room.
Immediate resuscitation efforts, including chest compressions and re-intubation, restored spontaneous circulation after three minutes. Crucially, a TEE probe was quickly deployed. The resulting images revealed a startling anomaly: the patient’s heart had shifted significantly to the right side of the chest cavity, deviating from its normal leftward orientation. The right and left ventricles appeared hyperdynamic, indicating forceful contractions, but the abnormal positioning was causing a dangerous torsion – twisting – of the superior and inferior vena cava, as well as the right atrium.
These findings strongly suggested cardiac strangulation or herniation, a condition where the heart protrudes through a defect in the pericardium – the sac surrounding the heart – and becomes compressed, obstructing blood flow. The TEE also showed a partially collapsed right atrium, a redundant wall, and a mass effect at the level of the interatrial septum, further supporting the diagnosis.
Responding to the urgent findings, the surgical team immediately reopened the patient’s chest. They repositioned the heart within the pericardium and meticulously closed the pericardial defect using a GORE-TEX® patch, a synthetic material commonly used in surgical repairs. The patient’s postoperative recovery was reportedly uneventful.
Cardiac herniation following pneumonectomy is an exceedingly rare but potentially fatal complication. The removal of a lung can alter the pressure dynamics within the chest cavity, creating a space where the heart can shift and become entrapped. The case underscores the importance of a high index of suspicion for this complication in patients undergoing pneumonectomy, particularly when faced with sudden hemodynamic instability post-operatively.
The use of TEE proved pivotal in this instance. TEE provides real-time, high-resolution images of the heart and surrounding structures, allowing clinicians to quickly identify anatomical abnormalities that might be missed by other diagnostic methods. Its portability and rapid deployment capabilities make it particularly valuable in emergency situations within the operating room.
While the case report focuses on a single patient, it aligns with a growing body of medical literature documenting the challenges associated with post-pneumonectomy syndrome. , reports indicate that this syndrome encompasses a range of complications, including airway collapse, as highlighted in recent publications from JACC Journals. Chronic cardiac herniation, though less acute, has also been documented as a peculiar diagnostic challenge, as noted in separate reports from Cureus.
The successful management of this case highlights the critical interplay between surgical expertise and advanced diagnostic imaging. The rapid identification of cardiac herniation via TEE allowed for prompt surgical intervention, preventing what could have been a fatal outcome. This case serves as a valuable reminder of the importance of preparedness and a multidisciplinary approach in managing complex surgical complications.
The rarity of post-pneumonectomy cardiac herniation means that standardized protocols for diagnosis and management are still evolving. Further research is needed to better understand the risk factors, optimal imaging strategies, and long-term outcomes for patients who experience this life-threatening complication. However, this case strongly advocates for the inclusion of TEE as a key diagnostic tool in the immediate post-operative assessment of patients undergoing pneumonectomy, particularly those exhibiting signs of hemodynamic instability.
