Twist and Shout
Acute Right Ventricular Failure Secondary to Cardiac Herniation and Pulmonary Artery Compression
A 61-year-old man was evaluated for hypotension and bradycardia after undergoing a left pleural pericardial pneumonectomy via a left thoracotomy for malignant mesothelioma. Past history was significant for coronary disease status after drug-eluting stent to the midleft anterior descending coronary artery 1 year before, hyperlipidemia, 25 pack-year smoking history, and malignant mesothelioma stage III. After the procedure, the patient was extubated without incident. He became hypotensive and tachycardic, requiring phenylephrine, vasopressin, and norepinephrine infusions in anesthesia recovery. Troponin T was trended at 0.17 ng/mL (normal, <0.01 ng/mL), to 0.93 ng/mL (at 3 hours), and peaked at 1.3 ng/mL (at 6 hours). On physical examination, the second heart sound was normal, and no right ventricular (RV) lifts, murmurs, rubs, or clicks were present. A chest tube was present in the left mediastinal space.
ECG demonstrated sinus tachycardia at a ventricular rate of 104 beats per minute, right axis deviation, and SIQIIITIII pattern (Figure 1), which were new findings compared with the previous ECG. …