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Diaphragmatic Hernias Following Left Ventricular Assist Device Explantation and Heart Transplantation: A Series of Both Laparoscopic and Open Repair

Kelly T Migliero1, Steven D Schwaitzberg1, David DeNofrio2
1New England Medical Center, Department Surgery, Boston, MA;2New England Medical Center, Devision Cardiology, Boston, MA

Objective: To examine the incidence, causality and surgical mangement of diaphragmatic hernia repair following heart transplant in pts with prior Left Ventricular Assist Device(LVAD) placement.
Design: Retrospective review of patients receiving Thoratec LVAD who developed diaphragmatic hernias from July 1999 until October 2004
Setting: Referral Center in Boston Massachusetts
Patients: 44 patients receiving Thoratec Heartmate LVAD Interventions: Chart Review
Main Outcome Measures: 1)Presence or absence of diaphragmatic hernia. 2)Outcome of surgical repair
Results: Of 44 patients receiving Thoratec LVAD for bridge to cardiac transplant, 28 patients were actually transplanted. Of these 28 patients 7(25%) developed diaphragmatic hernia after transplant. 5 of 7 underwent open hernia repair, 1 underwent laparoscopic repair, and one underwent laparoscopic converted to open repair. All diaphragms were repaired with a biologic patch. 2 patients had concomitant choleycystectomy, and 3 had ventral hernia repairs with mesh. Thus far there have been no mortalities and no recurrences to date.
Conclusions: Despite the fact that most LVAD canulae are placed anterior to the diaphragmatic leaf, trans-diaphragmatic hernias have been shown to be a common event post LVAD explantation and heart transplantation. Consideration should be given to biologic patch reinforcement of the diaphragm at the time of heart transplant and LVAD explantation. Therefore patients should undergo screening CT scan post heart transplant. The natural history of diaphragmatic hernias is such that they do get larger over time and should be fixed at the time that they are diagnosed. We have found that laparoscopy is a viable option for the repair of smaller diaphragmatic hernias.

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