Discussion
Surgical bleeding after LVAD placement typically occurs at cannulation
sites, driveline sites, or pump pockets.4 The
proponderance for erosion into surrounding structures is
well-recognized, but is generally associated with an intraperitoneal
pump pockets. Per our review of the literature, no cases of erosion into
the chest wall by and intrapericardial LVAD have been reported to date.
In this case, several factors suggest that hemorrhage resulted from
sustained contact between the pump housing and the chest wall.
Iatrogenic rib fractures from median sternotomies are not uncommon and
could certainly lacerate intercostal vessels. However, there was no
excessive spreading during this procedure, and postoperative chest
radiographs demonstrated no evidence of fracture. External cardiac
massage can also result in rib fractures, but the intercostal hemorrhage
clearly preceded chest compressions. Rather, we observed obvious erosion
of the pump housing through the overlying PTFE membrane and pericardium.
This aligned perfectly with the injured segment of the chest wall.
The presence of a rib fracture at this site suggests that the pump
housing can exert substantial force on adjacent structures. As such, a
diaphragmatic position should be strongly considered in the setting of
significant left ventricular dilation or massive cardiomegaly,
particularly in a thin patient. If the standard apical position is used,
a high index of suspicion must be maintained for chest wall trauma.
Ultrasound or two-view chest radiography should be used to assess for
injury if there is significant left-sided chest pain, and any evidence
of hemodynamic compromise should trigger immediate consideration of
surgical bleeding.