Abstract
Ventral hernias following left ventricular assist device (LVAD) placement are rare. With the improvement in technology, and miniaturization of devices associated with intrapericardial placement, these complications have largely been abolished. The mere presence of a large ventral hernia should not exclude recipients from being candidates for orthotopic heart transplantation.
Keywords: Heart failure, Left ventricular assist device, Heart transplant
Introduction
Ventral hernias, requiring surgical repair, are uncommon following left ventricular assist device (LVAD) implantation and have been rarely reported. However, due to improvements in technology and reduction in the size and technique of implantation, this problem is no longer seen. Postoperative complications such as bleeding, infection, and repeat interventions can potentially lead to the development of abdominal wall hernias [1, 2].
Case report
The patient was a 60-year-old obese gentleman (body mass index (BMI): 37.1 kg/m2) with uncontrolled type 2 diabetes mellitus (hemoglobin A1c of 10%). He was a known smoker in the past. The patient was diagnosed with non-ischemic cardiomyopathy in 1998. In August of 2013, the patient’s left ventricular ejection fraction (LVEF) of 15% with dilated left ventricle measuring 7.2 cm in diastole led to his LVAD (HeartMate II) implantation. Following LVAD placement, anti-coagulation regimen was interrupted due to gastrointestinal (GI) bleeding and episodes of epistaxis.
Two months after the initial implant, in October of 2013, he underwent subcostal pump exchange due to LVAD thrombosis. About one year later, in January of 2015, he had an LVAD pump pocket hematoma complicated by methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. The hematoma was evacuated, and an omental flap was performed to secure the pocket. In 2017, he presented to our hospital for transplant evaluation with a non-reducible large ventral hernia after being taken off the transplant wait-list at other centers (Figs. 1a, b and 2a-c).
Fig. 1.
a Profile picture of the ventral hernia. b Frontal picture of the hernia
Fig. 2.
a Scout film of computed tomogram (CT) outlining the location of the LVAD. b Sagittal section of CT of the abdomen showing hernia and contents. c Axial section of CT of the abdomen showing hernia and contents
In September 2017, he underwent LVAD explant and an orthotopic heart transplantation which was technically challenging in view of the proximity of the hernia to the pump pocket. The LVAD was explanted with the help of the Rultract® Retractor (Cleveland, OH). Hemostasis was performed using Aquamantys™ (Medtronic, Minneapolis, MN). The rest of the explant and implant of the donor heart proceeded in standard fashion. We meticulously avoided getting into the hernia sac. He continues to do well at follow-up.
Discussion
The dissection needed for the HeartMate II™ pocket, compared to the newer iterations, may lead to hematoma formation which can contribute to infection in the pump pocket. We believe that the patient’s obesity and diabetes along with repeat surgical interventions and pump pocket infection, requiring an omental flap, led to the development of a large ventral hernia. The greater omentum is easily harvested and used as a flap to take advantage of its high vascularity, anti-inflammatory properties, and its ability to fill dead space [3].
Meticulous candidate selection, attention to hemostasis during the index procedure, and optimum anticoagulation are keys to successful outcomes with LVADs. While a large ventral hernia can be intimidating, LVAD explantation and orthotopic heart transplantation can be safely accomplished.
Author contribution
All authors contributed equally to this manuscript.
Funding
None.
Declarations
Temple IRB determination of non-human research letter was obtained. The Temple IRB decided this report was NHRS (non-human research).
Informed consent
Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.
Human and animal rights statement
No animals or humans were used nor harmed for this research manuscript.
Conflict of interest
None.
Footnotes
Publisher's note
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References
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