A Patient With a Left Ventricular Assist Device Requiring Emergency Surgery for a Strangulated Umbilical Hernia: A...

BACKGROUND Patients with left ventricular assist devices (LVADs) who require emergency non-cardiac surgery are at high risk due to long-term anticoagulation and the consequences of underlying heart failure. Approximately 3.3% of LVAD patients require emergency abdominal surgery, which is associated with a higher in-patient mortality rate. This report describes the case of a 43-year-old man with an implantable cardioverter defibrillator (ICD) and a left ventricular assist device (LVAD) who required emergency surgery for a strangulated umbilical hernia. CASE REPORT A 43-year-old man with an ICD and an LVAD who had been taking warfarin and clopidogrel presented with a 2-day history of abdominal pain and vomiting. Physical examination revealed a strangulated umbilical hernia and a non-strangulated right-sided inguinal hernia. The strangulated portion of the small intestine was resected, then an end-to-end intestinal anastomosis and closure of the umbilical and inguinal hernias were performed. In the next 2 days he developed symptoms of intraperitoneal bleeding; therefore, a decision was made to totally withhold anticoagulant and antiplatelet medication and administer 2 units of packed red blood cells concentrate and 1 unit of platelet concentrate. Despite prolonged anticoagulation interruption, the patient survived without LVAD thrombosis or ischemic complications and was transferred to the LVAD implantation center. CONCLUSIONS This report aims to accentuate the high-stakes decisions made to maintain a balance between thrombotic and hemorrhagic risk in our patient. It is advisable to consult the specialized implantation center overseeing the patient's ongoing care before performing emergency surgery.