Cardiac herniation after minimally invasive cardiac surgery: an unusual potentially lethal complication.

A 37-year-old woman was referred to our institution for minimally invasive surgical repair of a partial anomalous pulmonary venous connection of the right upper pulmonary vein into the superior vena cava and a sinus venosus atrial septal defect. Diagnosis was refined on admission. The patient received routine preparation in the operating room by oral intubation, right radial arterial line, and a left jugular central venous pressure catheter. Peripheral superior vena cava cannulation (Medtronic Inc., Minneapolis, Minn) was used to reduce the length of the thoracotomy. Through a right posterolateral thoracotomy, cardiopulmonary bypass was performed, and the aorta was cross-clamped. On cardiopulmonary bypass, during surgical repair of the anomalous pulmonary venous drainage by baffling it into the left atrium with an autologous pericardial patch, hemodynamic instability and hypovolemia occurred, requiring plasma expanders and packed red blood cell transfusion. At discontinuation of the cardiopulmonary bypass, at routine transesophageal echocardiography examination, a massive left pleural effusion compressing the left lung was noted. Immediately, the thoracotomy was closed and the left side of the chest was drained. Inasmuch as the hemorrhage from the left chest tube was not diminishing and a left carotid artery puncture during left jugular vein cannulation was suspected, an immediate left lateral thoracotomy in the second intercostal space was performed to repair a tear at the origin of the left carotid artery. The patient was then transferred to the intensive care unit in stable hemodynamic condition and receiving moderate inotropic drug support. Postoperative chest radiograph in the intensive care unit showed a right-sided cardiac mass (Figure 1). This unusual finding was further investigated with thoracic computed tomography, which confirmed a cardiac