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.