Giant asymptomatic pulmonary herniation following minimally invasive mitral valve replacement | |
DOI: 10.5606/e-cvsi.2023.1475 | |
Ahmet Barış Durukan1, Alper Canbay2, Ertan Aydın3 | |
1Department of Cardiovascular Surgery, Liv Ankara Hospital, Ankara, Türkiye 2Department of Cardiology, Liv Ankara Hospital, Ankara, Türkiye 3Department of Thoracic Surgery, Liv Ankara Hospital, Ankara, Türkiye |
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Keywords: Minimally invasive surgical procedures, pulmonary herniation, thoracotomy | |
Minimally invasive valve procedures have become the standard procedure for valvular surgery. Right thoracotomy is the preferred incision
for mitral or tricuspid interventions. Complications regarding thoracotomy are almost always either overlooked or ignored. Pulmonary
herniation is not that infrequent, but mostly asymptomatic or masked. Pulmonary herniation through thoracotomy incision is the most
common presentation and is usually in a limited area. Herein, we present a 62-year-old female patient with giant pulmonary herniation that
did not cause any respiratory issues following minimally invasive mitral valve surgery. No treatment was required for pulmonary herniation.
She was only given full medical therapy for heart failure. |
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Minimally invasive cardiac surgery is a
frequently preferred option in the last two decades
for surgical valvular procedures, predominantly
right thoracotomy approach for mitral or tricuspid
pathologies.[1] The implemented advantages over
applicability and durability of the procedure include
lower pain and discomfort easing earlier return to
normal life.[2] However, reported drawbacks often
include recurrent valvular pathologies, and often
incision-related complications are either overlooked
or ignored and not reported. Pulmonary herniation is
an incision-related complication following minimally
invasive valvular procedures. Herein, we report a
case of giant pulmonary herniation following right
thoracotomy approach mitral valve replacement
surgery that does not cause any respiratory issues. |
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CASE PRESANTATION
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A 62-year-old hospitalized female patient treated
for heart failure was consulted with us for a visible
lung herniation during respiration. The patient had
a visible in-and-out movement of the respiratory
wall due to inflated and deflated pulmonary tissue,
and the herniated chest wall only consisted of skin
and subcutaneous tissue (Figure 1a and Video 1).
A mitral valve replacement surgery with the right thoracotomy approach was performed seven years
ago in a different center. The postoperative course
was eventful, with femoral access site nosocomial
infection treated with vacuum-assisted therapy.
The patient had a minor hernia that did not
cause any respiratory symptoms located above the
incision, which had gradually increased in size over
the years. https://e-cvsi.org/uploads/videos/1475-ECVSI-video.mp4 Plain chest X-ray revealed complete 12 ribs on the right side (no ribs were excised or removed during surgery), and computed tomography scan documented a great area of herniation of the pulmonary tissue (Figure 1b). The patient had a pacemaker implanted and advanced heart failure. The patient was left untreated for the hernia since it was asymptomatic, and the medical status of the patient would not allow a chest wall repair surgery under general anesthesia. |
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Pulmonary herniation is an infrequent diagnosis,
which can be either congenital or acquired; the latter
being traumatic, spontaneous, or pathologic. It can be occasionally encountered following thoracotomy.
Herniation is usually visible in males in contrast
to females since breast tissue masks the herniated
tissue. Patients usually complain of pain during
coughing. Unlike the patient presented here, patients
may complain of a persistent cough, dyspnea, and
haemoptysis.[3] Treatment is surgical with autologous
graft chest wall reconstruction.[4] The pathology itself
is not infrequent following surgical valvular procedures
with the right thoracotomy approach but is mostly
overlooked or ignored and consequently not reported. A detailed report of 20 cases stated that pulmonary herniation was an infrequent entity and minor herniations were more common.[4] The patient we reported has a very large area of pulmonary herniation, but the pathology did not cause any respiratory problem. The chest wall was flail with only skin and subcutaneous tissue covering the lungs. The patient’s dyspnea was caused by cardiac failure rather than pulmonary herniation. In conclusion, it should be kept in mind that pulmonary herniation may occur following minimally invasive mitral valve surgery. Minor herniations are more frequent. The treatment varies depending upon patient's condition. Patient Consent for Publication: A written informed consent was obtained from patient. Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Author Contributions: All authors contributed equally to the article. Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. Funding: The authors received no financial support for the research and/or authorship of this article. |
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1) Kofidis T, Chang G. How to set up a minimally invasive
cardiac surgery program? Turk Gogus Kalp Dama
2020;28:571-5. doi: 10.5606/tgkdc.dergisi.2020.09356.
2) Nakayama T, Nakamura Y, Yasumoto Y, Yoshiyama D,
Kuroda M, Nishijima S, et al. Early and mid-term outcomes
of minimally invasive mitral valve repair via right minithoracotomy:
5-year experience with 129 consecutive
patients. Gen Thorac Cardiovasc Surg 2021;69:1174-84. doi:10.1007/s11748-020-01573-2.
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