- Case report
- Open Access
Iatrogenic intrapericardial diaphragmatic hernia diagnosed by cardiovascular magnetic resonance
© Drafts et al; licensee BioMed Central Ltd. 2010
Received: 23 November 2009
Accepted: 8 January 2010
Published: 8 January 2010
Intrapericardial diaphragmatic hernias are very uncommon and are most typically caused by high-force blunt trauma. Other iatrogenic causes such as prior surgical formation of a pericardial window have been described, but are exceedingly rare. We present a case of an intrapericardial diaphragmatic hernia in a patient with a prior pericardial window in which the diagnosis was unclear using conventional imaging modalities, but was established using cardiovascular magnetic resonance.
Intrapericardial diaphragmatic hernias are very uncommon, and although they may be congenital they are more typically the consequence of prior trauma, interventional procedures, or prior surgery. If these pericardial hernias result in the presence of bowel within the pericardial sac, visualization of the heart and pericardial contents with echocardiography can be difficult or impossible. The limitation of echocardiography in this diagnosis is related to the fact that ultrasound beams are not transmitted through gas-containing structures such as bowel. Newer advanced multiplanar imaging modalities such as cardiovascular magnetic resonance (CMR) are not as affected by the presence of gas-containing structures around the heart, and thus allow for comprehensive visualization of the heart and pericardial contents to establish the correct diagnosis.
Intrapericardial diaphragmatic hernias have three known etiologies: traumatic, congenital, or iatrogenic. Traumatic herniation is the most common cause and is usually due to high-force blunt injuries or penetrating traumas to the chest or abdomen . Congenital causes are secondary to a developmental failure of the septum transversum, which can create a pericardio-peritoneal opening . Iatrogenic causes are extremely rare and can be caused by prior coronary artery bypass surgery , insertion of a pacemaker via an abdominal approach , or, as in the case we present, subxiphoid pericardial window for recurrent pericardial effusions.
Clinical presentations are variable and commonly include nonspecific cardiopulmonary or gastrointestinal symptoms that might delay the diagnosis. Prior reports have shown more critical presentations with associated complications including visceral strangulation, ischemic bowel, or cardiac tamponade, which would indicate emergent surgical reduction and repair . Our patient presented with pulsus paradoxus on physical exam with low voltage on ECG that might suggest cardiac tamponade in an unstable patient. However, our patient remained hemodynamically stable throughout his hospital course with preserved cardiac function. He also denied any abdominal pain, nausea, vomiting, or constipation that would suggest gastrointestinal compromise.
In the case we present, the diagnosis was established with CMR. The initial chest radiograph demonstrated a potential mediastinal hernia with the gastric bubble and loops of bowel superior to the diaphragm, but plain radiography cannot reliably confirm the presence of the bowel within the pericardial sac. While prior traumatic cases have been diagnosed with echocardiography , this modality was noncontributory in our case, as our patient's heart could not be visualized, secondary to the massive herniation of stomach and bowel anterior to the heart obscuring the ultrasound beam. Our case demonstrates the utility of advanced multiplanar imaging modalities such as CMR in establishing the correct diagnosis.
The true incidence of intrapericardial diaphragmatic hernias as a postoperative complication may have been underestimated prior to the advent of CMR. It is important to consider a diagnosis of intrapericardial diaphragmatic hernia in patients with pericardial windows who present with nonspecific cardiopulmonary or gastrointestinal symptoms. When such a diagnosis is suspect, and when conventional imaging modalities fail to yield a specific diagnosis, further evaluation with CMR should be considered.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
BCD, MD, Resident of Internal Medicine. HLC, MD, Fellow of Cardiology. DWE, MD, Assistant Professor of Radiology and Internal Medicine Section on Cardiology.
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