Emergent surgery for cardiac herniation coexisting with complex blunt cardiac injury: A case report

A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V-V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.