Interact CardioVasc Thorac Surg 2008;7:141-143. doi:10.1510/icvts.2007.165944
© 2008 European Association of Cardio-Thoracic Surgery
Negative results - Thoracic general |
Unusual late presentation of asymptomatic diaphragmatic hernia following ventricular assist device explantation
Teruya Nakamuraa,*,
Takushi Kohmotoa,
Walter G. Kaob,
Satoru Osakia,
Kierstyn L. Blocka and
Tracey L. Weigela
a Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
b Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
Received 30 August 2007;
received in revised form 30 October 2007;
accepted 31 October 2007
*Corresponding author. Department of Cardiovascular Surgery, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-Ward, Osaka 530-0001, Japan, Tel.: +81-6-6341-8651; fax: +81-6-6341-0785.
E-mail address: tnakamura{at}watanabe-hsp.or.jp (T. Nakamura).
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Abstract
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The role of left ventricular assist device (LVAD) in treatment options of congestive heart failure is becoming more important and the widespread application is imminent. There are, however, some serious complications associated with LVAD, which make patient management more challenging. We report a rare surgical case of asymptomatic diaphragmatic hernia, which was diagnosed 8.5 years after heart transplantation and LVAD explantation. A left mini (7 cm), muscle- and nerve-sparing thoracotomy was performed, and we found the splenic flexure of the colon herniated into the left pleural space through a small, circumferential defect of the diaphragm ( 4 cm in diameter) created for the inflow cannula of LVAD. The hernia was reduced and the defect was repaired.
Key Words: Diaphragm; Hernias; Heart failure; Left ventricular assist device; Transplantation-heart
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1. Introduction
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Although heart transplantation is on the mainstay of treatment of end-stage congestive heart failure, the role of left ventricular assist device (LVAD) has been emerging because of evolution of device technology as well as limited availability of donor hearts [1]. Since the U.S. Food and Drug Administration approved LVAD as a permanent treatment of end-stage heart failure (so-called ‘destination’ therapy), more patients on device support have required long-term support and multiple operations including device replacement. This places patients at risk of device-related complications, which are often devastating and even life-threatening [1]. Infection or abdominal complications such as abdominal wall hernia and/or bowel obstruction are often accompanied with long-term support and multiple operations.
We herein present our recent unusual case of asymptomatic diaphragmatic hernia, which occurred 8.5 years after successful LVAD explantation and heart transplantation.
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2. Case report
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A 57-year-old male was referred to our outpatient clinic for asymptomatic diaphragmatic hernia. Past medical history was significant for idiopathic dilated cardiomyopathy and end-stage congestive heart failure, for which he underwent HeartMate-IP® (Thoratec, Pleasanton, CA) LVAD implantation as ‘a bridge-to-transplant’ nine years prior to the presentation. After eight months of stable LVAD support, he successfully underwent heart transplantation and explantation of LVAD. Both operations were done at an outside hospital. Detailed chart review revealed that the device was placed in the preperitoneal space underneath the rectus abdominis muscle sheath, and a small hall was created on the left hemidiaphragm for the inflow cannula. When the device was explanted, the diaphragm was minimally dissected around the inflow cannula, and the small defect was not repaired. He had been doing well until 8.5 years after heart transplantation, when he returned to our cardiology clinic as a routine follow-up. Chest X-ray demonstrated a gas pattern consistent with diaphragmatic hernia (Fig. 1). Chest computed tomography scan demonstrated the herniation of the splenic flexure of the colon into the left pleural cavity. There was no evidence of bowel obstruction or incarceration. Previous chest X-ray films were retrospectively reviewed, and the hernia was not seen (Fig. 2). Due to potential risk of bowel strangulation, a decision was made to perform an elective surgery.
A left mini (7 cm), muscle- and nerve-sparing thoracotomy was performed along the anterior border of the latissimus dorsi muscle. The latissimus was reflected intact posteriorly and the serratus was reflected intact superiorly. The 6th intercostal nerve was incised off and the 6th intercostal space was entered on the top of the 7th rib. The hernia sac was easily identified and was adheded to the pericardium and the lung (Fig. 3). The circumferential defect of the diaphragm was 4 cm in diameter, located on the anterior surface of the hemidiaphragm, consistent with the transdiaphragmatic route of the inflow cannula. The rest of the diaphragm appeared intact. Circumferential dissection of the hernia sac was performed and the bowel contents were reduced into the abdominal cavity, with special care not to volvulize the colon. The defect was primarily closed using 0-ProleneTM (Ethicon, Somerville, NJ) horizontal mattress sutures with pledgets. Postoperatively, he did quite well and was discharged on postoperative day 2. At follow-up, there was no sign of bowel obstruction or recurrence of hernia.
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Fig. 3. Appearance of diaphragmatic hernia. Arrowhead: The left hemidiaphragm. Note that the hernia is adheded to the pericardium (black arrow) and the prepericardial fat (white arrow).
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3. Discussion
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Our case is unique for several reasons. First, the patient was asymptomatic and the hernia was diagnosed at a routine follow-up visit. These hernias are usually symptomatic with abdominal complaints [2–6], and are considered potentially lethal due to the risk of bowel incarceration and strangulation [6]. Second, the device was placed preperitoneally, which presumably decreases chances of abdominal complications. Previous reports described that the devices were placed intraperitoneal space [2–5]. Third, the hernia was found 8.5 years after the device explantation, and the reason of such a late onset remains unclear. In the largest series by Chatterjee et al. [5], the duration between device explanation and onset of diaphragmatic hernia is 8–42 months (mean: 20 months). Finally, although the hernia occurred through a relatively small hole of the diaphragm, it may have been preventable if the defect was closed upon device removal.
Although surgical correction of the hernia is strongly recommended to prevent potential bowel [2, 4–6], and/or pulmonary complications [3], the optimal approach is controversial. Laparotomy is a preferred option, as previously described [3–6]. Nevertheless, we found mini, muscle- and nerve-sparing thoracotomy quite useful, based on the following reasons. First, it was easier and safer to dissect the hernia sac from the surrounding intra-thoracic components via the ‘virgin cavity’ rather than the infected preperitoneal space. Second, the muscle- and nerve-sparing approach was patient-friendly, and it allowed for the patient discharge on postoperative day 2 secondary to immediate return of bowel function and lack of ileus that a transabdominal approach would have likely accompanied. Although a video-assisted thoracoscopic approach might also have been a good option, it is unlikely to have resulted in a shorter length of hospital stay or improved patient comfort.
In conclusion, it is crucial to be aware of the rare yet serious complication following LVAD explantation, which may be preventable by careful closure of the diaphragmatic defect. Once the diagnosis is made, a prompt surgical intervention is mandatory to prevent incarcerated hernia and subsequent life-threatening sequelae. Despite previous reports using laparotomy, transthoracic approach using mini, muscle- and nerve-sparing thoracotomy seemed a good option.
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References
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- Chen JM, Naka Y, Rose EA. The future of left ventricular assist device therapy in adults. Nat Clin Pract Cardiovasc Med 2006; 3:346–347.[CrossRef][Medline]
- Phillips WS, Burton NA, Macmanus Q, Lefrak EA. Surgical complications in bridging to transplantation: the Thermo Cardiosystems LVAD. Ann Thorac Surg 1992; 53:482–485.[Abstract]
- Mouly-Bandini A, Chalvignac V, Collart F, Caus T, Guidon C, Giudicelli R, Mesana T. Transdiaphragmatic hernia 1 year after heart transplantation following implantable LVAD. J Heart Lung Transplant 2002; 21:1144–1146.[CrossRef][Medline]
- Farma J, Leeser D, Furukawa S, Dempsey DT. Laparoscopic repair of diaphragmatic hernia after left ventricular assist device. J Laparoendosc Adv Surg Tech A 2003; 13:185–187.[CrossRef][Medline]
- Chatterjee S, Williams NN, Ohara ML, Twomey C, Morris JB, Acker MA. Diaphragmatic hernias associated with ventricular assist devices and heart transplantation. Ann Thorac Surg 2004; 77:2111–2114.[Abstract/Free Full Text]
- Chandra D, Gupta S, Reddy RM, Gregoric ID, Kar B. Gastric volvulus after ventricular assist device explantation and cardiac transplantation. Tex Heart Inst J 2007; 34:112–114.[Medline]
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Abstract
1. Introduction
