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 pericar-dial 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, hyperlip-idemia, 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 S I Q III T III pattern (Figure 1), which were new findings compared with the previous ECG. Lower extremity ultrasound was negative for deep venous thrombosis. Transthoracic echocardiogram illustrated a left ventricular ejection fraction of 70%, septal flattening during systole and diastole, an estimated RV systolic pressure of 54 mm Hg with severe tricuspid regurgitation secondary to severe annular dilatation, and severe RV enlargement with diminished RV systolic function. Repeat echocardiogram 12 hours later demonstrated further RV enlargement with worsening systolic function. The patient experienced recurrent hypotension and became unresponsive. Because of concerns for postoperative pulmonary embolism, an emergent chest computed tomography was performed and demonstrated left-sided cardiac herniation pos-teriorly through the left pericardiotomy with a cephalad rim of pericardium causing extrinsic compression and supravalvular narrowing of the main pulmonary artery with a cross-sectional diameter of 5×8 mm and no filling defects (Figures 2 and 3 and Movie I in the online-only Data Supplement). The patient was taken to the operating room emergently, and redo tho-racotomy revealed partial left cardiac herniation through the left-sided pericardiotomy with pericardial rim compressing the right pulmonary artery. The heart was repositioned within the mediastinum, and pericardial mesh placement closed the left-sided pericardiotomy to prevent subsequent malposition (Figures 4 through 6). Cardiac herniation is a rare but potentially lethal complication of right or left pneumonectomy. The herniation occurs through a pericardial defect and occurs most commonly after right pneumonectomy but can also result after left-sided pneumonectomy, as in the current case. Approximately 60 or more …