Cardiac herniation identified without any symptoms following extrapleural pneumonectomy: a case report

Our plain-English summary of Cardiac herniation identified without any symptoms following extrapleural pneumonectomy: a case report, by R. Tokuda, S. Ikebe, M. Inoue (General Thoracic and Cardiovascular Surgery Cases, 2025).

The study

• Authors: R. Tokuda, S. Ikebe, M. Inoue
• Journal: General Thoracic and Cardiovascular Surgery Cases
• Published: 2025;4(1):14
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Cardiac herniation, especially right-sided herniation, is a fatal complication which causes sudden hypotension due to obstruction of the vena cava. Here, we describe a case of cardiac herniation identified without any symptoms after right extrapleural pneumonectomy performed for diffuse pleural mesothelioma.

Case Presentation: A 72-year-old man with diffuse pleural mesothelioma underwent a right extrapleural pneumonectomy after chemotherapy. The tumor had widely invaded the pericardium, necessitating pericardial resection. The pericardial defect was approximately 10 × 6 cm and was reconstructed with a 0.1-mm polytetrafluoroethylene sheet. Routine chest radiographs taken just after the operation were normal. A chest radiograph on postoperative day one revealed cardiac herniation but he remained hemodynamically stable. An urgent re-thoracotomy was performed for pericardial reconstruction. Severe hypotension occurred immediately before the operation, but was improved upon placing the patient in the left lateral decubitus position. Postoperatively, he developed postoperative complications including chylothorax and empyema, and was discharged 118 days after surgery.

Conclusions: Cardiac herniation can occur without any symptoms following right pneumonectomy with pericardiectomy. Urgent reoperation is warranted due to the high risk of impending shock, even in hemodynamically stable patients.

© 2025. The Author(s).

In plain English

This case report described one patient: a 72-year-old man with epithelial-type diffuse pleural mesothelioma. The article did not describe any asbestos exposure. After three courses of cisplatin and pemetrexed chemotherapy, the patient had a right extrapleural pneumonectomy. Tumor had invaded the pericardium (the sac around the heart), and the defect of roughly 10 by 6 cm was patched with a 0.1-mm PTFE sheet. A chest X-ray in the operating room was unremarkable. One taken the next day showed the heart had shifted into the right chest (cardiac herniation), although vital signs were stable. About 3 hours later, before re-operation, blood pressure fell suddenly and improved when the patient was turned onto the left side. At re-operation the patch sutures had come loose, and the surgeons reconstructed the pericardium with a PTFE sheet and 13 more closely spaced stitches. The patient later developed chylothorax and empyema and was discharged 118 days after surgery. The patient then had tumor recurrence in the other lung and died 6 months after surgery. The authors concluded that this kind of herniation can occur without symptoms and needs urgent repair.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (one patient)
• Who was studied: One 72-year-old man with performance status 0 and no comorbidities. He had epithelial-type diffuse pleural mesothelioma, staged cT3 (pericardium) N0M0 stage IB, and was referred to the authors' hospital. The authors' department is at Fukuchiyama City-Hospital, Japan.
• Exposure: No asbestos or other occupational or environmental exposure is described. The treatments described were three courses of chemotherapy (cisplatin and pemetrexed) followed by right extrapleural pneumonectomy with resection of the pericardium and diaphragm.
• Main results:
  • During the first operation, the pericardial defect (about 10 by 6 cm) was reconstructed with a 0.1-mm polytetrafluoroethylene (PTFE) sheet using 10 interrupted stitches.
  • A routine chest radiograph in the operating room was unremarkable. A chest radiograph on postoperative day one showed the heart shifted into the right chest while the patient's vital signs were stable.
  • Before re-thoracotomy, 3 hours after the diagnosis, the patient developed sudden hypotension and raised central venous pressure. Blood pressure improved when the patient was placed in the left lateral decubitus position.
  • At reoperation, the sutures fixing the PTFE sheet had dislodged, and the pericardial remnant had ruptured posteriorly and inferiorly.
  • At reoperation, the surgeons reconstructed the pericardium using a 0.1-mm PTFE sheet and 13 horizontal mattress sutures with felt pledgets, with the stitches spaced more closely than in the initial procedure.
  • The authors judged that postoperative ventilation, chest drainage with a water seal, preoperative chemotherapy, and a large pericardial defect likely induced the right cardiac herniation in this patient.
  • The patient developed chylothorax and empyema after surgery and was discharged 118 days postoperatively.
  • The patient had tumor recurrence in the contralateral lung and died 6 months after surgery.
• The authors' conclusion: The authors concluded that cardiac herniation without symptoms, detected on chest radiography, is associated with impending hemodynamic shock and needs urgent pericardial repair, even when the patient is hemodynamically stable.

Topics

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Chemotherapy, Pericardium, Pericardial, Chest X-Ray, Thoracotomy, Empyema.

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• Diaphragmatic Herniation through Prosthetic Material after Extrapleural Pneumonectomy: Be Aware of Tumor Recurrence — D. Pop, C. Cohen, et al. (2013)
• Laparoscopic repair of gastric herniation after extrapleural pneumonectomy for mesothelioma — M. Egan, B.E. Louie, et al. (2012)
• Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy — D.J. Sugarbaker, A.S. Wolf, et al. (2011)
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