The patient, a 34-year-old woman (height 156 cm, weight 46 kg), showed symptoms of chronic cough, recurrent pulmonary infections, and pronounced stress dyspnea. Further evaluations revealed tuberculosis, treated several years with an unknown monotherapy. In the respiratory function test, forced vital capacity was 1.6 L (FVC 52%) and forced expiratory volume in 1 second was 0.91 L (FEV1 33.5%), indicating marked restricted lung function. A chest CT scan revealed right accentuated severe bronchiectasis accompanied by pulmonary emphysema (Figure 1). During a rigid bronchoscopy, a damage of the right main stem bronchus and massive purulent secretions of the right caudal lung sections (affected by Escherichia coli) were found. Lung ventilation-perfusion scintigraphy showed a distribution of ventilation of 90% on the left and 10% on the right side. Thus, decision for right pneumonectomy was made.
Induction and maintenance of anesthesia was uneventful. The patient received a left-sided double-lumen tube for one-lung ventilation, a central venous catheter in the right subclavian vein, and a radial arterial line. A thoracic epidural catheter was inserted for perioperative pain control. Pneumonectomy was performed through a lateral thoracotomy. To reduce the risk of postoperative bronchial stump dehiscence, the bronchial stump was covered with a pedicled pericardial flap, and the pericardial defect was immediately repaired with a Vicryl mesh. A chest tube was placed in the right cavity. At the end of surgery the patient was successfully extubated and transferred to the intensive care unit. The postoperative chest X-ray showed correct position of the central venous catheter and the chest tube (Figure 2).
A few hours later, the patient became hemodynamically unstable and showed an anemia (Hb: 6.7 g/dl). Because of an assumed intrathoracic hemorrhage and possible cardiac herniation (Figure 3), the patient was taken back to the operating room. On reopening of the thoracotomy, cardiac herniation into the right thoracic cavity because of a rupture of the Vicryl mesh was seen. A concomitant rupture of the right lower pulmonary vein and the left atrium was also observed. Surgical treatment included suture of the pulmonary vein and left atrium as well as repair of the pericardium with a Gore-Tex patch. Volume substitution for blood loss consisted of 1.500 lactated Ringer's solution, 1000 ml of 6% hydroxyethylstarch, and 600 ml packed red cells elevating hemoglobin to 10 g/dl.
During transfer of the patient to the intensive care unit after surgery, ventilation became increasingly difficult and again hemodynamical instability occurred. Carotid pulse was missing and invasive measured blood pressure displayed 39/31 mmHg. The patient received ephedrine (100 mcg) elevating blood pressure to 90/60 mmHg. A chest x-ray was made (Figure 4) which revealed an acute tension pneumothorax on the left side with mediastinal shift. An immediate needle decompression was attempted with a 16 G cannula at the left second intercostal space in the midclavicular line. The tension pneumothorax was successfully relieved and an intercostals tube (24 F) was inserted in the left fourth intercostal space in the midaxillary line (Figure 5). Following treatment of the tension pneumothorax, ventilation and cardiac output quickly normalized. The patient was uneventfully extubated 8 h later and discharged from the intensive care unit in stable condition on the third postoperative day. The cause of the tension pneumothorax remained unknown.