Case summary
A 54-year-old man with end-stage ischemic cardiomyopathy was admitted to
our center for LVAD placement. Echocardiography revealed a left
ventricular ejection fraction of 10% with an end-diastolic dimension of
8.5 cm. He was approved for a HeartWare HVAD (HeartWare International,
Framingham, MA), which was placed in the standard apical position via
median sternotomy (Figure 1). A polytetrafluoroethylene (PTFE) membrane
was placed over the pump housing and outflow graft, as is our usual
practice. Hemostasis was achieved quickly, and no intraoperative
complications were noted. Postoperatively, the patient complained of
severe left-sided chest pain despite appropriate analgesia. This was
attributed to poor pain tolerance and his narcotic dosing was increased.
No evidence of trauma or significant effusion was found on serial chest
radiographs; however, the pump housing appeared to contact the chest
wall in several films.
On postoperative day 4, LVAD flows acutely declined. Perfusion was lost
despite aggressive fluid resuscitation but was regained with high-dose
inotropic support and a brief period of external cardiac massage. A
chest radiograph at that time demonstrated a large left pleural
effusion. A chest tube was placed with immediate return of 2,200 mL of
frank blood. He was taken emergently to the operating room for
exploration. All anastomoses remained hemostatic; however, a massive
hemothorax was appreciated in the left pleural space. On further
examination, there was an area of pericardium and PTFE through which the
pump housing had eroded (Figure 2). The overlying rib was fractured and
denuded of periosteum, and the intercostal artery was bleeding briskly.
Hemostasis was achieved with electrocautery and the fractured rib
segment was removed. The remainder of his postoperative course was
uncomplicated and he was discharged home in stable condition one month
after his index procedure.