Bovine pericardium diaphragm repair of diaphragmatic hernia after LVAD explantation and heart transplantation

摘要

A 60-year-old male underwent a successful orthotropic heart transplant secondary to ischemic heart failure at our institution. He was bridged with a Heartmate II left ventricular assist device (LVAD) for a period of 2 years prior to an organ becoming available (Figure 1). The patient had an uneventful removal of the LVAD, orthotopic heart transplant and postoperative recovery. He was discharged home 12 days following his operation. He returned 1 month later for a scheduled, outpatient endomyocardial biopsy complaining of shortness of breath, increased fatigue and intermittent epigastric abdominal pain. Subsequent fluoroscopy during his biopsy was concerning for possible abdominal contents in his chest. A computed tomography (CT) scan confirmed the presence of a large diaphragmatic hernia with multiple loops of bowel in his thoracic cavity (Figure 2). He was taken to the operating room for reduction of his abdominal contents and repair of his diaphragmatic defect. A seventh intercostal space left thoracotomy was performed and provided adequate exposure of the hernia and facilitated the reduction of the contents. At the time of transplantation, the diaphragmatic defect had been reapproximated with 0 monofilament absorbable sutures. After reduction of the hernia, it was evident that the sutures had pulled through the diaphragmatic tissue to cause a single 5X3 cm defect. Given the failure of the previous repair, the defect was closed using a bovine pericardium patch (Figure 3). Postoperative hospital course was unremarkable. The patient was discharged on regular diet, with no lingering symptoms on postoperative day 8.