An 84-year-old woman suffered from a type IV diaphragmatic hernia with a tortuous intrathoracic stomach and grade II esophagitis. The stomach was reduced into the abdominal cavity and the hernia sac resected. A coated polyester mesh was attached to the crura with 5-mm titanium helical tacks. After an uneventful recovery, the patient suddenly developed cardiogenic shock on postoperative day 14. A left thoracotomy was subsequently performed. There was active bleeding of the epicardium from a number of pointed lesions, just opposite the tackers which had penetrated the pericardium. The offending tacks were removed and the defects in the epicardium sutured. The patient was discharged 18 days after thoracotomy.
A 50-year-old female with gastroesophageal reflux disease treated with omeprazole, with an endoscopy results of type I hiatal hernia, suggestive findings of Barrett's esophagus, chronic superficial gastritis and polyps on gastric corpus and fundus, along with a manometry revealing a nonspecific esophageal disorder, underwent an elective laparoscopic Nissen fundoplication with polytetrafluoroethylene mesh repair of the esophageus hiatus with no intraoperative complications. The patient was discharged on the first postoperative day and coursed asymptomatic for three days, reporting only mild epigastric pain and adequate food intake.\nOn the fourth postoperative day, she went to the ER after a witnessed syncopal episode with hypotension of 70/40 mmHg, tachycardia of 147 bpm, tachypnea of 30 bpm, and 35.5ºC of temperature. She was pale, notably, her external jugular veins were distended, with muffled heart sounds, normal abdominal examination showed no alteration on surgical wounds and she had delayed capillary refill; she integrated Beck’s triad, thus, cardiac tamponade was suspected, fluid therapy with lactate ringer’s solution was provided with adequate hemodynamic response, also omeprazole, analgesics, and antibiotics were administered.\nHer laboratory tests were: hemoglobin 11.5 g/dL, hematocrit 33.8%, platelet count of 370,000/HPF, leucocytes 12.8/HPF, neutrophils 8.9/HPF, D-dimer 1094 ug/L, creatinine 0.98 mg/dL, glucose 305 mg/dL. Electrocardiogram (ECG) showed sinus tachycardia and low voltage QRS complexes, the chest X-ray revealed pericardial effusion with a characteristic “water bottle sign” (Figure ), echocardiography reported 400 cc pericardial effusion coupled with right ventricular diastolic dysfunction and a left ventricle intramural hematoma. The CT scan demonstrated a close proximity of the tacks, used on her prior surgery for hiatal mesh fixation, to the inferior surface of the hearth (Figure ), with pleural and pericardial effusion (Figure ).\nOnce initial stabilization was achieved, the patient went to the ICU and underwent a failed attempt of ultrasound guided pericardiocentesis (PC), attributable to the hiatal mesh presence; therefore, the patient went into surgery, where a pericardial window was performed via thoracotomy; 300 cc of hematic pericardial effusion were drained along with approximately 600 cc of pleural effusion, two pleural drains were left in place.\nThe patient’s postoperative course was completely uneventful; an echocardiogram was performed 24 hours after surgery showing no pericardial effusion, thus the drains were removed when a minimal output was achieved on postoperative days 4 and 7, she was discharged asymptomatic 13 days after her intervention.