CASE REPORT Cardiac herniation after operative management of lung cancer: a rare and dangerous complication Jeroen E. H. Ponten • Ted W. O. Elenbaas • Joost F. ter Woorst • Erik H. M. Korsten • Ben E. E. M. van den Borne • Albert H. M. van Straten Received: 5 October 2011 / Accepted: 18 January 2012 / Published online: 25 May 2012 Ó The Japanese Association for Thoracic Surgery 2012 Abstract Cardiac herniation after pneumonectomy is recognized as a rare complication. This case report describes two cases. The mortality rate of this complication remains high as reported in the literature; in early-recognized cases 50 % and in late or unrecognized cases 100 %. In the fol- lowing two cases a pneumonectomy was performed as a treatment for lung cancer. Within 48 h after the initial operative treatment, the clinical situation of the patients got worse and radiographic examinations showed a strongly deviated heart. After suspicion of the diagnosis, the patients were immediately transferred to the operation theatre for emergency thoracotomy. Per-operative the diagnosis was confirmed and the heart was returned into its original posi- tion while the defect in the pericardial sac was closed with a bovine pericardial patch. Both patients survived these pro- cedures and did not suffer from any further complication. Keywords Cardiac herniation Á Pericardial hernia Á Cardiac luxation Á Luxatio cordis Á Pneumonectomy complication Introduction Cardiac herniation or luxation of the heart from the peri- cardial sac is a rare complication after pneumonectomy. The aetiology of cardiac herniation can be traumatic, in the setting of an accident or post-surgery or can be due to congenital defects in the pericardial sac [1]. The heart is herniated through the ruptured pericardial sac and in most cases also rotated around its axis, which causes torsion of the great arteries. As a complication after surgery it was first reported 1948 by Bettman et al. [2]. In that case Bettman describes a patient in whom a left pneumonec- tomy collapsed, when he was turned on his left side immediately after the operation. It was then noted that the heart had become angulated and strangulated through a pericardial defect. It was treated by sub-total removal of the pericardium. Recovery of the patient was complete and no untoward effects were seen after removal of the peri- cardium. After this first report of cardiac herniation by Bettmann et al. [2], several other cases were published with different outcomes. In our medical centre we had two cases in the past years that we will describe thoroughly. We perform around 90 pulmonary resections annually in our centre and the num- ber of total pneumonectomies have come down the last 5 years, from around 10 to 4 last year. Case report A Patient A, a male patient of 69 years old presented himself at our clinic with a persistent cough. Besides smoking (34 pack years) there was no relevant patient history. Physical examination was not aberrant; therefore a chest X-ray was performed (Fig. 1a). At the hilus of the right lung a solitary J. E. H. Ponten Á T. W. O. Elenbaas Á J. F. ter Woorst Á A. H. M. van Straten Department of Cardiothoracic Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands J. E. H. Ponten (&) Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands e-mail: jeroen.ponten@catharina-ziekenhuis.nl E. H. M. Korsten Department of Anaesthesiology and Critical Care Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands B. E. E. M. van den Borne Department of Pulmonary Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands 123 Gen Thorac Cardiovasc Surg (2012) 60:668–672 DOI 10.1007/s11748-012-0074-7