Blunt Traumatic Pericardial Rupture<br/>—Case Report and Literature Review

doi:10.4236/ss.2013.410086

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Surgical Science, 2013, 4, 438-442

http://dx.doi.org/10.4236/ss.2013.410086 Published Online October 2013 (http://www.scirp.org/journal/ss)

Blunt Traumatic Pericardial Ruptur e

—Case Report and Literature Review

Hongbin Wang*, Min Li

Department of Cardiac-Thoracic Surgery, Fengxian District Central Hospital,

Affiliated Hospital of Southern Medical University, Shanghai, China

Email: *[email protected]

Received May 15, 2013; revised June 14, 2013; accepted June 22, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Pericardial rupture following blunt chest trauma is rare and associated with high mortality rate ranging from 30% to

64%. We review 42 cases which have been reported in the literature in last 17 years and report a case of our own. We

have found that 83% of the cases were men with a mean age of 49 years. The most frequent cause was traffic accidents

(79%). Preoperative diagnosis of traumatic rupture of the pericardium has been improved in recent 17 years, and the

result is satisfactory. Early detection, timely treatment is the key. Pneumopericardium may be a valuable radiographic

clue for diagnosis. The management of pericardial rupture is mainly to avoid the risk of cardiac strangulation or acute

tamponade. If the injury is recognized timely, treatment is simple and effective.

Keywords: Traumatic Rupture of the Pericardium; Diagnosis; Management

1. Introduction

Pericardial rupture following blunt chest trauma is rare

and associated with high mortality rate ranging from

30% [1] to 64% [2]. If pericardial rupture is not detected

and treated promptly, it may be fatal owing to cardiac

herniation. Timely diagnosis can avert disaster because

surgical management is relatively simple and effective.

In this report, we review the cases communicated in the

literature in the last 17 years and report a new case of our

own. Relevant articles were identified by searching elec-

tronic databases (e.g., Medline, EMBASE, CENTRAL,

mRCT and Pascal), as well as the correspondent refer-

ences from 1994 to September 2011.

2. Case Report

A 36-year-old man suffering from a direct blow to the

left precordial chest arrived at the emergency department.

In the initial examination, he was found tachypneic with

abnormal breathing pattern on his left chest. His systolic

blood pressure was 85 mmHg and heart rate was 110/min.

A chest CT scan revealed left haemopneumothorax, bi-

lateral pulmonary contusion and left multiple ribs frac-

tures. Electrocardiogram showed generalized T-wave

inversion with sinu s tachycardia. His troponin I was 0.1 7

ng/ml (normal value < 0.04 ng/ml).

The patient was then transferred to the intensive care

unit (ICU). A left-sided chest tube evacuated 800 ml

blood within two hours. His systolic blood pressure

dropped to 82 mmHg with heart rate up to 120/min. Then

an emergent operation was decided. The approach was

through a left anterolateral thoracotomy. At operation,

700 ml blood was sucked out, and a left pericardial rup-

ture was found at the left diaph ragmatic pericardium. The

tear was vertical, 5.5 cm long. A complete pericardiot-

omy was performed, the left ventricle was intact with

wine surface. There was no visible bleeding. Then the

fixation of the broken ribs was done. The patient was

back to ICU. His troponin I dropped to normal on the 9th

postoperative day (or POD#9). Echocardiography showed

pericardial effusion with left ventricular diastolic dys-

function two weeks later. The patient was found postop-

erative sinus tachycardia with heart rate of 120 - 130/min.

Metoprolol 25 mg was given two times a day, and the

heart rate dropped to 100/min. The patient was dis-

charged 2 weeks later. The follow-up Electrocardiogram

showed normal sinus rhythm two months later.

3. Discussion

The most recent literature review about the traumatic

rupture of the pericardium was reported by Gallego in

*Corresponding a uthor.

H. B. WANG, M. LI 439

1996, with 40 cases collected between 1983-1993 [3].

Since 1994, we hav e found documents for 42 new cases,

[4-37] most of which are isolated case reports. In our

review, we have considered age and sex of the patients,

mechanism, associated lesion, diagnosing methods, com-

plications, treatment and corresponding outcome.

3.1. Epidemiology

The epidemiologic dates are summarized in Table 1, 35

male cases (83.3%) and 7 female cases (16.7%). The

average age was 49 years (18 - 83). The most frequent

cause was traffic accident (33 cases, 78.6%), the second

frequent cause was fal l i ng ( 6 cases, 14.3 %).

3.2. Associated Lesions

Associated lesions are presented in Table 2. The rib frac-

tures (50%) were the most common ones and the lesions

of the bones (47.6%) were the second common ones. The

abdominal lesions and head injuries were also very

common (correspondingly 28.6% and 26.2%).

3.3. Diagnosis

The methods used to diagnose the rupture of the pericar-

dium were showed in Table 3. In Gallego’s collection,

only 20% of the total 40 cases were diagnosed by diag-

nostic investigations before surgery. 80% of the cases

were diagnosed casually during surgical operation for

other unrelated lesions. In our collection, 38.1% of the

total 42 cases were diagnosed preoperatively by CT scan

and chest radiograph. Compared with Gallego’s collec-

tion [3], it is a great progress. This indicates that doctors’

ability of diagnosing traumatic rupture of the pericardium

has been gradually improving. In many cases, the pa-

tients got diagnosis and treatment promptly before sur-

gery, and the mortality and morbidity were reduced suc-

cessfully. But the diagnosis of traumatic pericardial rup-

Table 1. Epidemiology.

Parameters N %

Total cases 42 100

Sex

Men 35 83.3

Women 7 16.7

Mean age (years) 49

Mechanism of injury

traffic accident 33 78.6

Fall 6 14.3

Crush 3 7.1

Table 2. Summary of injuries associated with pericardial

rupture.

Injuries N %

Fractures of th e ribs 21 50

Pulmonary contusion 13 31.0

Pneumothorax/hemopneumothorax 9 21.4

Pneumopericardium 2 4.8

Pneumopericardium and Pneumothorax/

hemopneumothorax 10 23.8

Pneumomediastinum 7 16.7

Cardiac lesions:

Atrial 2 4.8

Ventricular 3 7.1

Intrapricardial vessels 6 14.3

Rupture of the diaphragm 9 21.4

Abdominal lesio n s 12 28.6

Lesions of the bones 20 47.6

Head injuries 11 26.2

Table 3. Methods used to diagnosis pericardial rupture (N =

42).

N %

Thoracotomy 13 31.0

Celiotomy 7 16.7

CT scan and Chest radiograph16 38.1

CAT scan 2 4.8

Thoracoscopic examination 2 4.8

TVR (CPB) 1 2.4

Echocardiography 1 2.4

TVR (CPB): Tricuspid valve replacement (Cardiopulmonary Bypass).

ture is still a big challenge because of non-specific clini-

cal symptoms and shortage of the physical signs, espe-

cially for those patients without card iac herniation . In our

case, the patient had neither clinical symptoms nor

physical signs that suggested the possibility of pericardial

rupture. The patient was operated through thoracotomy

because of hem orrhage and hypotension.

The electrocardiogram was usually normal or showed

non-specific abonormalities and had no help for the di-

agnosis of pericardial rupture. Pneumopericardium may

be a valuable radiographic clue. In the event of pneu-

mopericardium, the Macklin effect is the major cause

[38], but the pericardial space may also be connected

H. B. WANG, M. LI

440

directly to the pleural cavity or tracheobronchi as a con-

sequence of pericardial tear. In our collection, 23.8% of

the total cases complicated with pneumopericardium and

pneumothorax/hemopneumothorax and got preoperative

diagnosis. Pneumopericardium together with pneu-

mothorax/hemopneumothorax may imply existing peri-

cardial rupture. Displacement or apparent enlargement of

the heart could be noted sometimes. Thoracoscopic ex-

amination may be a useful method for the diagnosis [26].

By this way, not only co uld w e kno w the diagno sis of th e

disease, but also the necessity of the tear repair.

The rupture of the pericardium could result from se-

vere complications. In our collection presented in Table

4, 50% of 42 patients complicated with cardiac herni-

ation, 16.7% of them complicated with diaphragmatic

hernia. 3 of them died of cardiac herniation although the

diagnosis was completed preoperatively. Herniated heart

could lead to sudden death because of strangulation and

circulatory blockage. Patients with cardiac herniation

could die of ventricular dysfunction or multiple organs

failure in spite of urgent thoracotomy [14]. For some

cases, delayed cardiac herniation may take place, in

Clark’ report, a patient developed symptoms 5 years after

the cardiac hernia diagnosis and died of cardiac strangu-

lation suddenly.

3.4. Surgical Management

Not all of the pericardial tears need repair. In our case,

we managed the tear by a complete pericardiotomy. Our

collection showed that 71.4% of the lesions were re-

paired with patch, 4.8% of them were managed by

wound enlarged, and 9.5% of them were not repaired. It

is advisable to repair a tear of 8 - 12 cm in size because

of the risk of prolapse and strangulation of the heart [3].

In order to avoid the risk of acute tamponade, the com-

plete pericardiotomy operation is strongly recommended,

especially for those patients with cardiac confusion or

arrhythmia complications. For those cases complicated

with rupture of the diaphragm, the broken pericardium

does not need to be stitched.

3.5. Outcome

The final outcome of patients with pericardial rupture

depends on the associated injuries and the prompt recog-

nition of a pericardial tear in the multiply traumatized

patient. The relation of updated public cases of pericar-

dial rupture due to blunt thoracic trauma was showed in

Table 5. In our collection, six of the 42 patients (14.3%)

died, 3 of them die of atrial/intrapricardial vessels rupture,

one die of asystole, one die of right ventricular dysfunc-

tion and renal failure(family give up), 1 case die of se-

vere craniocerebral trauma. Compare with Clark’ [39]

and Gallego’s collection, the mortality is low, but it is

difficult to tell the mortality of the pericardial rupture

alone, because of some cases die of several associated

lesions.

Cardiac herniation may result in vascular collapse and

sudden death. But interestingly, there have been several

reports of asymptomatic luxation of the heart [40-42].

According to these reports, none of the patients devel-

oped hemodynamic instability. All of those patients with

a right dislocation of the heart didn't have the strangula-

tion of the outflow tracts.

4. Conclusion

From the literature review and our own case we conclude

Table 4. Complication of the pericardial rupture and treat-

ment.

Parameters N %

Total cases 42 100

Complication

Cardiac herniation 21 50

Traumatic diaphragmatic hernia 7 16.7

Treatment of the tear

Repaired 30 71.4

Not repaired 4 9.5

Wound enlarged 2 4.8

Table 5. Relation of to date public cases of pericardial rupture due to blunt thoracic trauma.

Associated injury to

Period Reference no. N of patients Heart Aorta

recoveries deaths

1706-1937 4 84 47 3 2 60

1937-1982 11 142 40 4 99 38

1982-1985 7 16 4 1 14 2

1983-1993 16 40 8 0 23 17

1994-2011 present series 42 5 2 36 6

H. B. WANG, M. LI 441

that, in spite of nonspecific symptoms and diagnosis dif-

ficulty, preoperative diagnosis of traumatic rupture of the

pericardium has been improved in recent 17 years, and

the result is satisfactory. Early detection and timely

treatment is the key. Pneumopericardium may be a valu-

able radiographic clue for diagnosis. Cardiac herniation

with right dislocation may prevent strangulation of the

outflow tracts from happening. The management of peri-

cardial rupture is mainly to avoid the risk of cardiac

strangulation or acute tamponade. If the injury is recog-

nized timely, treatment is simple and effective.

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