Traumatic pericardial rupture with secondary cardiac herniation in a dog.

OBJECTIVE: To describe the unique finding and treatment of a dog with cardiac herniation due to traumatic pericardial rupture. CASE SUMMARY: A 6.5-year-old entire male Yorkshire Terrier was presented for further management after being hit by a car. Despite suspected significant intrathoracic trauma at that time, the patient regained hemodynamic stability and had orthopedic surgery to correct a right iliac fracture. The patient was readmitted to the hospital 12 days following the initial visit due to considerable respiratory difficulty after accidentally being dropped several feet. Thoracic radiographs revealed an unusual severe mediastinal shift to the left with an atypical position of the cardiac silhouette against the left lateral thoracic wall. Due to the severe respiratory compromise of the patient and newly developed pneumothorax, an exploratory thoracotomy was recommended, where a complete rupture of the pericardium was identified, with secondary left-sided prolapse of the heart. Other more common intrathoracic injuries (ie, lung perforation, rib fractures) were also identified and partially repaired. The patient recovered successfully and was discharged 4 days postoperatively. NEW OR UNIQUE INFORMATION PROVIDED: This is the first case report in the veterinary literature of traumatic pericardial rupture and cardiac herniation. According to human case descriptions, this is a rare and often fatal occurrence, which can be significantly challenging to diagnose preoperatively or antemortem. Emergency veterinary clinicians should be aware of this rare but important complication of blunt thoracic trauma. Surgical intervention may be necessary in cases with suspected or confirmed entrapment of great vessels or cardiac chambers, although these abnormalities were not present in this case.

Right-sided luxation of the heart caused by blunt traumatic pericardial rupture.

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.

Urgent Surgical Treatment of Blunt Chest Trauma Followed by Cardiac and Pericardial Injuries.

INTRODUCTION: Widespread opinion that penetrating chest injuries are more urgent, in terms of treatment and care, contributed to underestimation of the urgency of blunt chest trauma, which in most cases is treated conservatively. It remains an open question frequency when the injuries of the heart and pericardium are not timely diagnosed and surgically treated. AIM: To demonstrate the importance of well-timed surgical treatment of blunt chest trauma, when coupled with cardiac and pericardial injuries. METHODS: At the Thoracic Surgery Clinic of the University Clinical Centre Banja Luka, Bosnia and Herzego vina, during period of 10 years (01.01. 2008 - 31.01.2018.), the total of 66 patients were treated for urgent thoracotomy due to clinically and radiologically unclear findings after blunt chest trauma. In general, diagnostic examinations, apart from laboratory analysis, included radiological imaging and Multi Slice Computed Tomography (MSCT) of the chest, followed by an ultrasound of the heart in cases when sternum was injured or when pericardial tamponade was suspected. Results presented in the study where obtained from the retrospective analysis of patients data. This work presents a retrospective observational cross-sectional study, which results in the assessment of the correctness of a particular diagnostic test. STATISTICAL METHODS USED: descriptive statistics, counting measures (frequencies and percentages), central tendency measures (arithmetic mean), variability measures (standard deviation). RESULTS: Sixty six patients were treated with urgent thoracotomy after a blunt trauma of the chest due to the unclear clinical and radiological finding. In the case of 11 patients (10 men and 1 woman), presenting 16.6% of the total sample, pericardial and cardiac injuries were detected and treated intraoperatively. Further, in the case of the one patient, pericardiotomy and suturing of the right heart chamber where performed, with the creation of a pericardial window. Transthoracic echocardiogram was not used as the primary screening module, but rather as a diagnostic test for patients who had unexplained hypotension and arrhythmia. Radiographs of the chest showed cardiomegaly with or without epicardial fat pad sign suggesting a pericardial effusion. CONCLUSION: Blunt cardiac and pericardial injuries represent a serious therapeutic problem, which, if not treated properly, result in a high mortality rate. Echocardiography is the primary diagnostic method for initial detection of pericardial effusion. Pericardial fluid first accumulates posterior to the heart, when the patient is examined in the supine position. As the effusion increases, it extends laterally and with large effusions the echo-free space expands to surround the entire heart. The size of the effusion may be graded as small ( echo free spaces in diastole <10 mm, corresponding to approxymately 300 ml), moderate (10-20 mm, corresponding to 500 ml), and large ( >20 mm, corresponding to >700 ml). When the ability of the pericardium to stretch is exceeded by rapid or massive accumulation of fluid, any additional fluid causes the pressure with the pericardial sac. Early recognition, pericardiotomy with pericardial window creation and/or ventricular rupture suture remain the "gold standard" in the treatment of blunt cardiac and pericardial injuries.

Novel Use of the Urchin® Heart Positioner for Repair of Pericardial Rupture in Cardiac Subluxation: Case Report and Review of Management.

A 65-year-old man was involved in a multivehicle collision from which he sustained blunt polytrauma involving the abdomen and chest. Imaging of the chest revealed biventricular cardiac herniation into the left chest with an associated pneumopericardium. He underwent emergent surgical management with repositioning of the heart and repair of associated pericardial rupture. Exposure was facilitated with the novel use of an off-pump coronary surgery heart positioner. This report highlights the management of these rare blunt traumatic injuries in addition to using the Urchin® heart positioner for optimal exposure.

Transvenous management of cardiac implantable electronic device late lead perforation.

INTRODUCTION: Late lead perforation (LLP), defined as perforation ≥30 days from cardiac implantable electronic device implant, is a rare diagnosis and little data exist regarding management practices and outcomes. The purpose of this study was to evaluate the occurrence, safety, and efficacy of transvenous management of clinically significant LLP. METHODS: The electronic medical records of a single-center tertiary hospital were reviewed for all patients who were referred for LLP or its sequelae. RESULTS: Eleven consecutive patients were identified from October 2011 to December 2018 with clinically significant LLP. Patients most often presented with pericardial symptoms with the exception of one asymptomatic patient. The median time from lead implant to intervention for LLP was 246 days. Nine patients were managed with an initial transvenous approach, with one requiring sternotomy (lead 6.3 years old). Two patients had a surgical approach, one performed at an outside hospital with subsequent death and another had a mini-thoracotomy, but the lead was removed percutaneously with no surgical repair. In this small cohort, there was no association between the lead extending beyond the parietal pericardium and surgical repair (P = .99). CONCLUSION: Our single-center experience suggests that LLP can be initially managed with a cautious transvenous approach in most patients, but intraprocedural ultrasound for pericardial monitoring and a rescue plan with immediate surgical back up is mandatory.

Surgical Removal of Migrated Broken Sternal Wire Using Endoscopic Assistance.

Patients undergoing sternotomy routinely undergo sternal closure with stainless steel wires. Occasionally these wires can fracture, although normally this presents no concern as the broken wire remains fixed and is not problematic. We report a case of a segment of a broken sternal wire that migrated through the pericardium onto the right ventricular. It was removed with a minimally invasive approach with endoscopic assistance.

Ventricular tachycardia and chest pain due to foreign body in the pericardium caused by self-injurious behaviour.

A 14-year-old girl suddenly developed ventricular tachycardia and severe chest pain during hospitalisation for trauma surgery. CT revealed a needle in the pericardium. Careful interview elicited that she had inserted the needle by herself, and Munchausen syndrome was diagnosed. This is the first report of ventricular tachycardia caused by a foreign body in a patient with Munchausen syndrome.

Radiation-Associated Pericardial Disease.

PURPOSE OF REVIEW: This review highlights the literature related to pericardial injury following radiation for oncologic diseases. RECENT FINDINGS: Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols. As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.

Large Epicardial Hematoma After Percutaneous Coronary Intervention: Multimodality Imaging.

Epicardial hematoma can manifest immediately or within a few minutes to hours after coronary intervention. Review of angiogram after the diagnosis of hematoma, in our case, showed deep distal positioning of a non-polymer jacketed wire, which is the most likely cause of the adverse outcome. Multimodality imaging is critical for diagnosis and management of such cases.

Intracardiac pulsed field ablation: Proof of feasibility in a chronic porcine model.

BACKGROUND: Radiofrequency (RF) has become an accepted energy source for myocardial ablation but may result in discontinuous lesions and nontargeted tissue injury. We examined the feasibility and safety of lesion formation using high-amplitude, bipolar pulsed electric fields delivered from a multielectrode array catheter. OBJECTIVE: The purpose of this study was to compare duty-cycled radiofrequency ablation (RFA) to pulsed field ablation (PFA) in terms of acute electrical effects, 2-week lesion formation, and injury to nontargeted tissues. METHODS: Intracardiac ablations were performed in 6 pigs using a circular pulmonary vein ablation catheter. The energy source for ablation delivery was randomized to deliver either PFA or RFA to 3 atrial endocardial sites. Bipolar pace capture and electrogram amplitude measurements were recorded at each site. Histopathology and necropsies were performed after 2 weeks. RESULTS: The circular pulmonary vein ablation catheter was used to deliver pulsed electric fields to produce cardiac lesions without skeletal muscle stimulation. Evaluating all ablations in each site, electrogram amplitudes were reduced to <0.5 mV in 67.5% of PFA vs 27.0% of RFA deliveries (P <.001). Bipolar cardiac capture was lost after 100% vs 92.0% of PFA vs RFA (P = .005). At 2 weeks, PFA resulted in consistent transmural and homogeneous replacement fibrosis devoid of lingering myocyte "sequesters." RFA lesions showed a stronger inflammatory response extending to the epicardial fat, arterial injury, and thrombosis. Neither PFA nor RFA lesions showed endocardial thrombus. CONCLUSION: Intracardiac PFA can be feasibly delivered from a circular catheter to create fibrotic lesions that have acute electrical effects, without injury to nontargeted tissue.

A Diaphragmatic Hernia and Pericardial Rupture Caused by Blunt Injury of the Chest: A Case Review.

Blunt traumatic diaphragmatic hernias are most commonly seen in combination with other injuries. Right diaphragmatic ruptures with serious pericardium ruptures are relatively rare. The diagnosis of diaphragmatic hernias is not difficult; however, prior to surgery, it is difficult to judge whether pericardium damage has occurred, particularly on the right side. This injury may occur in a critical pathological state in which cardiac tissue is outside the pericardium due to the pericardial defect. Severe hemodynamic disorders or even death may occur if the patient's condition is not diagnosed and treated in a timely manner. The transportation of patients with severe trauma must be performed with extreme caution. It is necessary to weigh a wide range of differential diagnoses in a serious and thorough initial investigation.

Calculated Decisions: Focused Assessment With Sonography for Trauma (FAST)

Focused Assessment with Sonography for Trauma (FAST) predicts the presence of pericardial or intra-abdominal injury after penetrating or blunt trauma.

[Rabbit Model for Evaluation of Anti-adhesive Materials after Open Heart Surgery].

Surgical trauma to the pericardial mesothelium during open heart procedures has formation of fibrovascular adhesions. Surgeons are confronted with cardiac adhesions, leading to an increased surgical risk such as intractable bleeding and possible catastrophic hemorrhage. In order to solve the problem, the anti-adhesion membrane has been developed and used. However, their performances are far from perfect, so it has been expected to develop a novel anti-adhesive material. For preparing an anti-adhesive material, there is 1 serious problem, a lack of golden standard of animal model for evaluation of anti-adhesivity. In this study, we tried to establish a standard system for evaluation of the performance of anti-adhesive materials for the chest-area surgery using rabbit. Setting the condition of the damage to heart, the objective evaluation system was established. And we performed experimental study to evaluate prevention of adhesions with pericardial substitutes and our product under development based on this model.

Delayed Presentation of Traumatic Pericardial Rupture: Diagnostic and Surgical Considerations for Treatment.

Traumatic pericardial rupture is a rare event with high mortality. We present the case of a 15-year-old boy who sustained thoracic and abdominal trauma secondary to motor vehicle collision, with a delayed diagnosis of traumatic pericardial rupture with cardiac herniation. Out of concern for torsion and hemodynamic collapse, surgical repair was advised. We have developed a novel surgical approach to this rare condition, utilizing a combination of thoracoscopic and open surgical techniques. The guiding principles of our repair include the utilization of fenestrated pieces of bovine pericardium to create a tension free repair, minimizing the likelihood of pericardial effusion, and returning the cardiac mass to normal anatomic position.