Severe hemodynamic deterioration caused by cardiac herniation during endoscopic thoracic sympathicotomy in a patient with previously undiagnosed congenital pericardial defect

provided the original work is properly cited. CC Congenital pericardial defect is a rare but potentially fatal disorder as it can cause severe hemodynamic compromise. Its asymptomatic nature and lack of diagnostic roles in chest radiography or electrocardiography (ECG) make diagnosis difficult [1]. We report a case of a patient with previously undiagnosed pericardial defect, who developed ST elevation and severe hemodynamic deterioration during endoscopic thoracic sympathicotomy. A 24-year-old male (172.2 cm, 74.8 kg) with a history of being a healthy hepatitis B carrier and having a congenital fusion of the cervical vertebrae was scheduled for repair of hyperhidrosis by endoscopic thoracic sympathicotomy. He had no previous cardiopulmonary symptoms, but preoperative ECG showed left posterior fascicular block. Chest radiography revealed an enlarged left atrial appendage (Fig. 1). For premedication, glycopyrrolate 0.2 mg, midazolam 2.0 mg, and famotidine 20 mg were administered. Preoperative vital signs were blood pressure (BP) 110/70 mmHg, heart rate (HR) 64 beats per minute (bpm), and oxygen saturation (SaO2) 98–99%. General anesthesia was induced with propofol 120 mg and rocuronium 50 mg. Intubation was performed using a 7.5 ID endotracheal tube. The operation began and the patient was placed in a reverse Trendelenburg position with the left side tilted upwards. To obtain a wider surgical field, carbon dioxide (CO2) was insufflated into the thoracic cavity with a maximum pressure of 10 mmHg at a flow rate of 1 L/min. Adhesiolysis was required since adhesions between the left lung and the mediastinum hindered visualization of the sympathetic ganglion. The operation was uneventful until the left lung was pulled from the heart toward the chest wall during adhesiolysis, and the dissected cardiac border was protruding out of the mediastinum. Almost immediately, the patient’s ECG developed ST elevation, and the BP abruptly dropped to 62/32 mmHg. The operation