“Prancing” Heart With Pericardial Injury
Pericardial injury is a rare complication of trauma. In fact, a previous report showed that pericardial damage was a complication in only 59 of 20 000 trauma patients at a level 1 trauma center. Of those, 29% had only damage to the pericardium, and only 3% of patients were diagnosed through diagnostic imaging.1
A 67-year-old man sustained blunt trauma after falling from a height of 10 m during forestry work. On physical examination, his Glasgow Coma Scale score was 15. His respiratory rate was 26 breaths per minute with a 99% oxygen saturation on 6 L supplemental oxygen per minute. His heart rate was 95 bpm and blood pressure was 90/50 mm Hg. Breath sounds were decreased on auscultation.
Anteroposterior chest radiographs showed a collapsed left lung, but the cardiac shadow and trachea appeared normal (Figure 1A). Computed tomography of the chest was then performed, which revealed that the heart was herniated through the damaged pericardium onto the collapsed left lung. Surprisingly, the heart was prancing intensely with each beat in the thoracic cavity (Figure 1B). An ECG showed sinus tachycardia, low voltage in all leads, clockwise rotation, and poor R-wave progression (Figure 2). Therefore, a diagnosis of hemopneumothorax and pericardial injury caused by blunt trauma was made. In addition, he had severe pain in the low back because of a pelvic fracture. A thoracic drainage tube was inserted to aspirate air and blood. The patient also underwent emergent transcatheter arterial embolization of the left superior gluteal artery. Pericardial closure via a thoracotomy was performed the next day. Intraoperative thoracoscopy confirmed the presence of myocardium exposed through the pericardium and a collapsed left lung (Figure 3 and Movies I and II in the online-only Data Supplement). Subsequently, open reduction and internal fixation of the pelvic fracture was performed on the fourth hospital day. His postoperative course progressed favorably, and he was discharged from the hospital 5 weeks after admission.
The heart appeared to be prancing in the thoracic cavity because it was no longer fixed in place as a result of the pericardial injury. Of note, the heart was swinging horizontally toward the thoracic wall. Therefore, it was difficult to detect the prancing heart on anteroposterior chest x-rays.
In this case, the pericardial damage was associated with pleuropericardium along the left phrenic nerve. Previous studies have reported that the most common location of pericardial rupture was the left pleuropericardium (62%), followed by the diaphragmatic portion of the pericardium (22%).2 In this case, the most important finding was that pericardial damage was not complicated by myocardial injury. Cardiac herniation is often diagnosed during emergent thoracotomy for hemodynamic instability. Hemodynamic deterioration associated with changes in patient position may be a clue to cardiac strangulation.3 This patient was hemodynamically stable, and cardiac herniation was detected by computed tomography, along with left pneumothorax. Herniation of the heart as a result of pericardium rupture often causes death by strangulation. Therefore, even if the hemodynamics was stable, it is necessary to perform a careful examination and assessment of patients with blunt thoracic trauma.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.015582/-/DC1.
- © 2015 American Heart Association, Inc.