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“Prancing” Heart With Pericardial Injury
Kodai Suzuki, MD; Hideshi Okada, MD, PhD; Tetsuya Fukuta, MD; Shozo Yoshida, MD;
Takahiro Yoshida, MD; Narihiro Ishida, MD, PhD; Katsuya Shimabukuro, MD, PhD;
Hisashi Iwata, MD, PhD; Hiroaki Ushikoshi, MD, PhD; Izumi Toyoda, MD, PhD;
Hirofumi Takemura, MD, PhD; Shinji Ogura, MD, PhD
P
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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.
ericardial 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.
Disclosures
None.
References
1. Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM, Cowley
RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979–1989). J Trauma. 1991;31:167–172.
2. Galindo Gallego M, Lopez-Cambra MJ, Fernandez-Acenero MJ, Alvarez
Perez TL, Tadeo Ruiz G, Vazquez Santos P, Ortega Lopez M. Traumatic
rupture of the pericardium: case report and literature review. J Cardiovasc
Surg (Torino). 1996;37:187–191.
3. Wall MJ Jr, Mattox KL, Wolf DA. The cardiac pendulum: blunt rupture of the pericardium with strangulation of the heart. J Trauma.
2005;59:136–141.
From Department of Emergency and Disaster Medicine (K. Suzuki, H.O., T.F., S.Y., T.Y., H.U., I.T., S.O.) and General and Cardiothoracic Surgery (N.I.,
K. Shimabukuro, H.I., H.T.) , Gifu University Graduate School of Medicine, Gifu, Japan.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.
115.015582/-/DC1.
Correspondence to Hideshi Okada, MD, PhD, Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1
Yanagido, Gifu 501-1194, Japan. E-mail [email protected]
(Circulation. 2015;131:e397-e398. DOI: 10.1161/CIRCULATIONAHA.115.015582.)
© 2015 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.115.015582
e397
e398 Circulation April 7, 2015
A
B
Figure 1. A, Anteroposterior chest radiograph. The red arrows indicate the outline
of the collapsed left lung. B, Computed
tomography of the chest (lung window).
The green arrows indicate the pericardium. The heart was swinging horizontally in the thoracic cavity.
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Figure 2. ECG on admission. ECG
revealed sinus tachycardia (heart rate,
101 bpm), low voltage in all leads, clockwise rotation, and poor R-wave progression. There was also a wavy baseline.
A
B
Figure 3. A, Thoracoscopy was performed through the eighth
intercostal space before pericardial repair. B, Thoracoscopy
showed the collapsed left lung and exposed myocardium.
''Prancing'' Heart With Pericardial Injury
Kodai Suzuki, Hideshi Okada, Tetsuya Fukuta, Shozo Yoshida, Takahiro Yoshida, Narihiro
Ishida, Katsuya Shimabukuro, Hisashi Iwata, Hiroaki Ushikoshi, Izumi Toyoda, Hirofumi
Takemura and Shinji Ogura
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Circulation. 2015;131:e397-e398
doi: 10.1161/CIRCULATIONAHA.115.015582
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2015 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/131/14/e397
Data Supplement (unedited) at:
http://circ.ahajournals.org/content/suppl/2015/04/07/CIRCULATIONAHA.115.015582.DC1
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