Case summary
A 54-year-old man with end-stage ischemic cardiomyopathy was admitted to our center for LVAD placement. Echocardiography revealed a left ventricular ejection fraction of 10% with an end-diastolic dimension of 8.5 cm. He was approved for a HeartWare HVAD (HeartWare International, Framingham, MA), which was placed in the standard apical position via median sternotomy (Figure 1). A polytetrafluoroethylene (PTFE) membrane was placed over the pump housing and outflow graft, as is our usual practice. Hemostasis was achieved quickly, and no intraoperative complications were noted. Postoperatively, the patient complained of severe left-sided chest pain despite appropriate analgesia. This was attributed to poor pain tolerance and his narcotic dosing was increased. No evidence of trauma or significant effusion was found on serial chest radiographs; however, the pump housing appeared to contact the chest wall in several films.
On postoperative day 4, LVAD flows acutely declined. Perfusion was lost despite aggressive fluid resuscitation but was regained with high-dose inotropic support and a brief period of external cardiac massage. A chest radiograph at that time demonstrated a large left pleural effusion. A chest tube was placed with immediate return of 2,200 mL of frank blood. He was taken emergently to the operating room for exploration. All anastomoses remained hemostatic; however, a massive hemothorax was appreciated in the left pleural space. On further examination, there was an area of pericardium and PTFE through which the pump housing had eroded (Figure 2). The overlying rib was fractured and denuded of periosteum, and the intercostal artery was bleeding briskly. Hemostasis was achieved with electrocautery and the fractured rib segment was removed. The remainder of his postoperative course was uncomplicated and he was discharged home in stable condition one month after his index procedure.