Diaphragmatic hernias associated with ventricular assist devices and heart transplantation

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.

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.

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.

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.