Strangulated diaphragmatic hernia from left ventricular assist device: Plea to close diaphragmatic defect at the time of device explantation

Akshay Pratap¹, Maria Albuja-Cruz¹, Tiffany Tanner². ¹University of Colorado, ²University of Nebraska

Introduction: LVAD [left ventricular assist device] has emerged as a mainstay of destination therapy or bridge to heart transplant in patients with end-stage cardiac disease. Despite the tremendous success with LVAD devices, device related and procedure related complications contribute to significant morbidity in these patients.  Diaphragmatic hernia is a known complication. We report two cases of diaphragmatic hernias who underwent LVAD explantation without closure of diaphragmatic defect and orthotopic heart transplant, which resulted in strangulation of small bowel and incarceration of stomach respectively.

Case 1: A 70-year-old man presented to our emergency room with the chief complaint of epigastric and central abdominal pain. He denied any recent trauma to chest or abdomen. He had undergone LVAD 5 years ago followed by explantation of LVAD and orthotopic heart transplantation 4 years ago.  The diaphragmatic defect for the outflow cannula was not closed at the time of LVAD explantation. An upright chest x-ray and a computed tomography showed a closed loop small bowel obstruction through a diaphragmatic defect with significant stranding of the mesentery of the herniated bowel and mass-effect on the right ventricle of the heart. Laparoscopic resection of strangulated jejunum and closure of defect with a biological mesh was successfully performed. He made an uneventful recovery and was discharged on POD#5.

Case 2: A 52 year old female with a history of LVAD bridge to heart transplant presented with nausea and hematemesis. An upright chest xray and CT scan showed a large diaphragmatic hernia with stomach in left hemithorax. She underwent a laparoscopic reduction of stomach. Stomach was viable. The defect was closed primarily with a composite Parietex mesh.  She made an uneventful recovery and was discharged on POD#3.

Conclusion: Emerging technological advancements in cardiac mechanical devices is a new paradigm in the care of patients with end-stage heart failure. There is ongoing debate whether to close the diaphragmatic aperture for the inflow or outflow cannulas of LVAD device at the time of explantation. We believe closure of the diaphragmatic defect should be done, as it may prevent life threatening catastrophic complications in an immunosuppressed patient.

Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 88160

Program Number: P041

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster