Abstract
BackgroundVentricular rupture is rarely described in the literature outside the context of myocardial infarction, infection or neoplasm. It is associated with a high mortality rate due to late presentation and delayed surgical intervention, which involves sutureless or sutured techniques. Comprehensive literature review failed to identify any case of intra-operative right ventricular heart rupture followed by myocardial repair and a complete recovery after a prolonged intensive care unit (ICU) stay.Case presentationA 57-year-old previously healthy gentleman presented complaining of a new onset shortness of breath for 2 months. A large mediastinal mass was found on chest imaging and biopsy revealed a thymoma. Patient received a neoadjuvant Cisplatin/Doxorubicin/Cyclophosphamide (CAP) regimen chemotherapy then sternotomy and thymectomy en bloc with anterior pericardium. Post-thymectomy, the patient continued to be hypotensive in recovery despite aggressive fluid resuscitation. He was sent back to theatre, aggressive fluid resuscitation continued, surgical site exploration was done by reopening the sternum, and the bleeding source was identified and controlled, but intraoperative asystole developed. During internal cardiac massage, the right ventricle ruptured with a 3 cm defect which was successfully repaired using a pericardial patch without a bypass machine due to unavailability at our cancer center. The patient remained dependent on mechanical ventilation through tracheostomy for a total of 2 months due to bilateral phrenic nerve paralysis, was discharged from ICU to the surgical floor 66 days after the operation and weaned off ventilator support after 85 days, adequate respiratory and physical rehabilitation followed. Patient is doing very well now with excellent performance, and free of tumor recurrence 30 months after surgery.ConclusionRight ventricular rupture is rarely described outside the context of myocardial infarction and valvular heart disease. Tumor proximity to the heart and neoadjuvant cardiotoxic chemotherapy are the proposed causes for precipitating the cardiac rupture in our case. Post-surgical patients who receive early physical rehabilitation and respiratory physiotherapy have improved survival and outcome.
Highlights
Thymic epithelial tumors originate from typical epithelial cells and include thymomas and thymic carcinomas [1, 2]
Neoadjuvant chemotherapy, using CAP regimen, is advised to be followed by an evaluation for surgery in cases deemed un-resectable initially [18], an effect that was documented in our patient that resulted in the shrinking of the thymic mass
Several studies published by Padro, Lijoi, and Mariani, who reported 13, 2, and 1 patient respectively, reported ventricular free wall rupture repair due to myocardial infarction without Cardio-Pulmonary Bypass (CPB) and without any complication post-operatively [32,33,34]
Summary
Thymic mass resection is associated with a risk of bleeding, post-operative wound infection, recurrence, and injury to adjacent structures. We report a case of a 57-year-old previously healthy gentleman, who was diagnosed with an invasive thymoma, treated with chemotherapy followed by surgical resection. He spent more than 2 months in the ICU following an incidence of cardiac rupture during an attempt of CPR. Being a tertiary cancer center, we do not have the equipment needed to perform cardiac bypass surgeries in the event of cardiac rupture. We were forced to use basic techniques in order to save our patient’s life which we enhanced by vigorous and yet adequate chest and whole body physiotherapy that we believe resulted in his fast recovery and returning to his normal life
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