https://orcid.org/0000-0003-3465-5681
A 67-year-old woman was brought to the emergency department following a motor vehicle accident with blunt chest wall trauma. She was hypotensive and in acute respiratory distress requiring emergent endotracheal intubation. Contrast computed tomography showed bilateral pneumothoraxes and a levorotated posteriorly directed cardiac apex with herniation out of the pericardial sac (Panel A).
Transoesophageal echocardiogram (TOE) demonstrated a decompressed left atrium with an anteriorly displaced ascending aorta and an underfilled and hyperdynamic left ventricle (Panels B and C). The right atrium appeared enlarged with the interatrial septum bowing towards the left atrium with normal right ventricular size and function (Panels D and E). The patient was taken emergently to the operating room and was found to have her heart herniating into the left chest with torn pericardium anteriorly to the course of the phrenic nerve. The heart was repositioned, and the pericardial defect was repaired with a bovine pericardial patch.
Rapid deceleration can cause tearing of the pericardium along the phrenic nerve in a saw-like mechanism. Pericardial rupture is a rare complication of acute blunt chest wall trauma with a high mortality rate secondary to obstructed pulmonary venous return by kinking of the pulmonary veins at the left atrial junction.
Levorotation of the heart with posteriorly dislocated apex and anteriorly displaced ascending aorta should raise suspicion for cardiac herniation and prompt emergent surgery, avoiding delay for further diagnostic testing. TOE allows for rapid diagnosis of pericardial rupture, excludes other causes of hypotension, and can support intraoperative clinical decision-making.
