Ann Thorac Surg 2004;77:2111-2114
© 2004 The Society of Thoracic Surgeons
Original article: cardiovascular
Diaphragmatic hernias associated with ventricular assist devices and heart transplantation
Subhasis Chatterjee, MDa,
Noel N. Williams, MDb,
Mary Lou Ohara, MSNa,
Carol Twomey, CRNPc,
Jon B. Morris, MDb,
Michael A. Acker, MDa*
a Cardiothoracic Surgery, Philadelphia, Pennsylvania USA
b Gastrointestinal Surgery, Philadelphia, Pennsylvania USA
c Cardiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Accepted for publication October 8, 2003.
* Address reprint requests to Dr Acker, Chief of Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, 6 Silverstein Pavilion, 3400 Spruce St, Philadelphia, PA 19104-4227, USA
e-mail: michael.acker{at}uphs.upenn.edu
 |
Abstract
|
|---|
BACKGROUND: Diaphragmatic hernias in heart transplant recipients with prior left ventricular assist device (LVAD) placement are a potentially life-threatening complication. This review examined the incidence, diagnostic strategies, surgical management, and prevention of diaphragmatic hernias in these patients.
METHODS: A retrospective review of patients receiving a Thoratec HeartMate (Thoratec Laboratories Corp, Pleasanton, CA) LVAD who developed a diaphragmatic hernia after VAD explantation and orthotopic heart transplantation (OHT). Two groups were identified and their results compared. In the early group, the diaphragmatic defect was not closed at the time of OHT and VAD explantation, while in the late group the defect was closed.
RESULTS: In the early group, between September 1995 and November 1999, a total of 61 HeartMate LVADs were placed intraperitoneally as a bridge to transplantation, and 44 of those patients went on to OHT. Of these patients, 7 of 44 (15.9%) developed a diaphragmatic hernia after transplantation. Five of the patients underwent successful surgery by laparotomy without recurrence. Two patients with asymptomatic diaphragmatic hernia await repair. After a modification in diaphragmatic closure after VAD explantation at the time of OHT, in the late group between November 1999 and July 2002, 29 HeartMate LVADs were placed and 23 patients went on to OHT. There has been one diaphragmatic hernia (1 of 23, 4.3%) in this group.
CONCLUSIONS: Diaphragmatic hernia following VAD placement and heart transplantation requires an aggressive diagnostic and therapeutic approach in this immunosuppressed patient population. We recommend primary closure of all diaphragmatic defects at the time of OHT and VAD explantation to reduce the incidence of this complication.
|
Introduction
|
|---|
Left ventricular assist devices (LVADs) provide a "bridge to transplant" allowing for mechanical circulatory support until a donor heart is available. Survival to transplantation with LVAD support is between 70% and 80% [1, 2]. In addition, the prospectively randomized evaluation of mechanical assistance for the treatment of congestive heart failure (REMATCH) trial has demonstrated that the Thoractec HeartMate (Thoratec Laboratories Corp, Pleasanton, CA) vented electrical LVAD can be used successfully to destination therapy, and is superior to medical treatment in end-stage heart failure patients not suitable for transplantation [3].
The HeartMate LVAD is a totally implantable, pneumatically driven device that is positioned either preperitoneally or intraperitoneally in the left upper quadrant underneath the costal margin, with the driveline brought out through the abdominal wall and attached to a portable console or batteries. After VAD explantation and heart transplantation there are two potential sites of diaphragmatic herniation (Fig 1).
First is the transdiaphragmatic defect located in the left hemidiaphragm where the original VAD inflow cannula penetrated. Second is the anterior diaphragmatic defect where the outflow cannula entered, which is similar in location to the congenital retrosternal diaphragmatic hernia of Morgagni. This review examines the incidence, treatment, and prevention of this complication in our series.
View larger version (36K):
[in this window]
[in a new window]
|
Fig 1. Diagram of vented electrical HeartMate LVAD and sites of the two diaphragmatic defects. The transdiaphragmatic defect is in the left hemidiaphragm, and the anterior diaphragmatic defect is in the midline. (LVAD = left ventricular assist device.) (With permission from the Thoratec Laboratories Corp.)
|
|
|
Patients and methods
|
|---|
A retrospective chart review, which covers the inception of our VAD program from September 1993 to August 2002, included a total of 90 Thoratec HeartMate LVADs that were placed in an intraperitoneal position as a bridge to transplantation at our institution by six different surgeons. This consisted of 47 implantable pneumatic left ventricular assist systems (IP-LVAS) with 31 of those patients going on to orthotopic heart transplantation (OHT), and 43 vented electrical (VE-LVAS) VADs (36 to OHT). We looked at the incidence of diaphragmatic hernia complications in the group of patients who received a Thoratec HeartMate LVAD and went on to OHT. During this time, a total of 183 total VADs (LVAD, RVAD, and BiVAD) were placed in 172 patients (9 received a sequential RVAD after RV failure post-LVAD) at our institution, and 103 of those patients went on to OHT.
The study was divided into two groups, based upon the technique of diaphragmatic closure. In both groups, the transdiaphragmatic defect was closed primarily at the time of VAD explantation and OHT. However, in the early group the anterior diaphragmatic defect was not closed at this time, while in the later group this defect was closed at the time of VAD explanation and OHT. This was done by mobilizing the anterior edge of the diaphragm and attaching it to the costal margin with interrupted, nonabsorbable suture. Toward the midline the edge of the diaphragm is incorporated into the midline closure, and if this is under tension the repair was augmented with nonabsorbable mesh.
Data and statistical analysis
All data are reported as means with standard deviation.
|
Results
|
|---|
In our early group without complete primary diaphragmatic closure of both defects, diaphragmatic hernias occurred in 7 of 44 (15.9%) patients who received an intraperitoneal HeartMate LVAD and went on to OHT. Two patients presented emergently with colonic incarceration, two with subacute complaints (vague abdominal discomfort) in an outpatient setting, and three asymptomatic patients were found to have an incidental diaphragmatic hernia on annual screening chest radiograph. Each diaphragmatic hernia was located through the anterior diaphragmatic defect, and the time to development of the diaphragmatic hernia from heart transplantation ranged from 8 to 42 months with a mean of 20.3 ± 14.3 months. Of the 5 patients who have undergone surgery, the average length of stay was 7.8 ± 2.2 days, and 3 of 5 patients required mesh closure of the diaphragmatic defect. Average follow-up is 32.5 ± 19.2 months with no recurrence or complications associated with diaphragmatic hernia repair. Patient characteristics are noted in Table 1.
Since the modification in closure technique to address both diaphragmatic defects at the time of OHT and VAD explantation, 27 patients underwent HeartMate LVAD implantation, and 23 of them went on to OHT. There has been one (1 of 23) diaphragmatic hernia in this later group. This patient presented with subacute complaints 17 months after OHT with a diaphragmatic hernia through the transdiaphragmatic defect. He underwent successful repair without mesh placement. There have been no diaphragmatic hernias through the anterior diaphragmatic defect since this modification in our closure technique.
|
Comment
|
|---|
A MEDLINE review of the English literature from 1966 to 2002 revealed two reported cases of a diaphragmatic hernia after placement of a ventricular assist device in a heart transplant recipient. Mouly-Bandini and colleagues [4] reported a case of a transdiaphragmatic hernia in a patient two years after heart transplantation following a Novacor left VAD. Phillips and colleagues [5] reported a patient presenting with a diaphragmatic hernia having previously received the Thermo Cardiosystems (TCI; Thermo Cardiosystems, Inc, Woburn, MA) Model 14 "Heart Mate" LVAD, the same device used in our patients. Eight months after heart transplantation, the patient presented with abdominal discomfort and vomiting. At laparotomy, a portion of the stomach, colon, and omentum had herniated into the pericardium and left pleural space. After repair, the patient recovered uneventfully.
In our series, in the earlier group diaphragmatic hernias were noted with a defect in the anterior portion of the diaphragm, where the VAD outflow cannula was originally located and the defect was not closed. Because the transdiaphragmatic defect was closed where the VAD inflow cannula was located, the incidence of DHs in this location was much less. Initially, it was felt that primary repair of the anterior diaphragmatic defect after VAD explantation would be neither advisable, since it would add to the operative time, nor necessary, since the scarring in the midline would prevent herniation. However, we have since modified our closure technique to primarily repair the anterior diaphragmatic defect at the time of VAD explantation in the later group.
Patients become symptomatic from diaphragmatic hernias with abdominal pain and risk visceral herniation. The most commonly herniated viscus is the colon, followed by the stomach, small bowel, and spleen, respectively [6]. This follows our experience with colonic herniation (5 of 5 patients), stomach (3 of 5 patients), and small bowel (2 of 5 patients). Herniation of intraabdominal organs can have profound hemodynamic consequences by diminishing ventricular filling resulting in a decrease in ejection fraction, a reduction in cardiac output, and cardiac arrest [7].
The initial diagnostic evaluation includes a chest radiograph and a computed tomographic scan of the chest and abdomen. An upper-gastrointestinal study with water-soluble contrast may delineate the anatomy more precisely and demonstrate an intrathoracic stomach (Fig 2).
In addition, a gastrograffin enema to evaluate for colonic incarceration can demonstrate herniation of the colon.
Surgical repair involves transdiaphragmatic lavage and closure of the hernia. Most agree that in the management of acute diaphragmatic hernia from penetrating trauma, the transabdominal approach is favored. In the setting of a late diagnosis, on the other hand, some argue that the preferred approach for a traumatic diaphragmatic hernia should be a thoracic approach because of the frequent presence of marked adhesions between the herniated viscus and pulmonary parenchyma [8, 9].
In our experience, however, the laparotomy through a midline incision is the preferred approach with some clear advantages. First, because of dense intraabdominal adhesions between the liver and the central portion of the diaphragm, and significant left upper quadrant adhesions between the transverse colon, spleen, and splenic flexure where the original LVAD was situated, the abdominal approach allowed careful adhesiolysis and mobilization of this portion of the diaphragm and abdominal viscera that would not have been possible with a thoracotomy alone. Second, unlike the delayed presentation in the trauma setting in which patients are more likely to have had abdominal rather than thoracic surgery, in the VAD/OHT setting, all patients have had at least two prior median sternotomies resulting in a chest more extensively scarred than the abdomen. In addition, VAD-related diaphragmatic hernias are predictably located in one of two locations (the anterior or transdiaphragmatic defects where the cannulas penetrated), whereas the traumatic diaphragmatic hernias tend to be located in a more posterolateral position. Third, although one was not needed in our case, certainly any resection of the bowel would require a laparotomy.
Thus, our recommendation is to begin with a laparotomy with extension to a left thoracotomy if necessary. In our series of five patients who underwent repair, all were successfully repaired by laparotomy without need for extension to a thoracotomy. Patients should have 24 hours of clear liquids before surgery and routine bowel preparation. After the abdomen is entered and adhesiolysis is performed, the contents of the hernia sac can usually be reduced with gentle traction (Fig 3).
For repair of the defect (Fig 4),
we prefer 1 to 0 or larger monofilament nonabsorbable sutures (polypropylene). Larger defects are best repaired utilizing nonabsorbable bioprosthetic meshes; eg, polypropylene, polyester cloth, or expanded polytetrafluoroethylene. Moreover, it is especially important to be careful repairing the central portion of the diaphragm where the original VAD outflow cannulas were near to avoid accidental myocardial puncture or laceration. At the completion, administering a large tidal volume and visualizing diaphragmatic motion can test the integrity of the repair.
Although diaphragmatic hernias are a rare complication after VAD placement and heart transplantation, in the setting of vague abdominal complaints or acute bowel incarceration it is a possibility that must be kept in mind. Consequently, an aggressive diagnostic and therapeutic approach must be practiced with a low threshold of suspicion. Some groups have advocated the routine implantation of the LVAD in a preperitoneal pocket above the posterior rectus sheath and below the rectus muscle because of decreased incidence of intraabdominal complications [10]. We, however, believe that the preperitoneal approach increases the incidence of pocket complications, seromas, and localized infections. Thus, we favor an intraabdominal approach with primary closure of all diaphragmatic defects and resuspension of the anterior diaphragm with mesh if needed at the time of heart transplantation and VAD explantation.
|
References
|
|---|
- McCarthy P.M., Smedira N.O., Vargo R.L., Goormastic M., Hobbs R.E., Starling R.C. One hundred patients with the HeartMate left ventricular assist device: evolving concepts and technology. J Thorac Cardiovasc Surg 1998;115:904-912.[Abstract/Free Full Text]
- Sun B.C., Catanese K.A., Spanier T.B., Flannery M.R., Gardocki M.T., Marcus L.S. 100 long-term implantable left ventricular assist devices: the Columbia Presbyterian interim experience. Ann Thorac Surg 1999;68:688-694.[Abstract/Free Full Text]
- Rose E.A., Gelijns A.C., Moskowitz A.J., et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435-1443.[Abstract/Free Full Text]
- Mouly-Bandini A., Chalvignac V., Collart F., et al. Transdiaphragmatic hernia 1 year after heart transplantation following implantable LVAD. J Heart Lung Transplant 2002;21:1144-1146.[Medline]
- Phillips W.S., Burton N.A., Macmanus Q., Lefrak E.A. Surgical complications in bridging to transplantation: the Thermo Cardiosystems LVAD. Ann Thorac Surg 1992;53:482-486.[Abstract]
- Hegarty M.M. Delayed presentation of traumatic diaphragmatic hernia. Ann Surg 1978;188:229-233.[Medline]
- Murray J., Demetriades D., Ashton K. Acute tension diaphragmatic herniation: case report. J Trauma-Injury Infection & Critical Care 1997;43:698-700.
- Nano M., DeiPoli M., Mossetti C., Maggi C. Traumatic diaphragmatic hernias. Surg Gynecol Obstet 1980;151:191-192.[Medline]
- Kilic D., Nadir A., Doner E., Kavukcu S., Akal M., Ozdemir N. Transthoracic approach in surgical management of Morgagni hernia. Eur J Cardiothorac Surg 2001;20:1016-1019.[Abstract/Free Full Text]
- McCarthy P.M., Schmitt S.K., Vargo R.L., Gordon S., Keys T.F., Hobbs R.E. Implantable LVAD infections: implications for permanent use of the device. Ann Thorac Surg 1996;61:359-365.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
T. Nakamura, T. Kohmoto, W. G. Kao, S. Osaki, K. L. Block, and T. L. Weigel
Unusual late presentation of asymptomatic diaphragmatic hernia following ventricular assist device explantation
Interactive CardioVascular and Thoracic Surgery,
February 1, 2008;
7(1):
141 - 143.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. S. Groth, B. A. Whitson, J. D'Cunha, R. S. Andrade, and M. A. Maddaus
Diaphragmatic hernias after sequential left ventricular assist device explantation and orthotopic heart transplant: Early results of laparoscopic repair with polytetrafluoroethylene
J. Thorac. Cardiovasc. Surg.,
January 1, 2008;
135(1):
38 - 43.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
