Left ventricular apical infection and rupture complicating left ventricular assist device explantation in 2 women with postpartum cardiomyopathy

A Rare and Late Complication After Left Ventricular Assist Device Explantation

Late complications can arise after explantation of a left ventricular assist device. We report the case of a patient who presented at the age of 19 years with peri-partum cardiomyopathy and was initially managed with a biventricular support device, which was subsequently upgraded to an ambulatory left ventricular assist device. This was successfully explanted after myocardial recovery via a minimally invasive approach 7 months later. The patient re-presented 5 years following explantation with hemoptysis. At redo sternotomy, a 10-cm remnant of the outflow graft was found to be eroding the surface of the right lung. The conduit was excised and the stump oversewn. Eleven months later, she presented again with hemoptysis, and a pseudo-aneurysm was identified on the computed tomography scan. She underwent urgent open repair with peripheral cannulation and deep hypothermic total circulatory arrest. The Dacron stump was found to be partially dehisced, leaving a 2-3 cm defect in the ascending aorta. The defect was repaired with a bovine pericardial patch. The patient made a good recovery and was successfully discharged.

Imaging of left ventricular device complications

Left ventricular assist devices have become an increasingly common life-extending therapy for patients with end-stage heart failure. These devices may be used as a bridge to transplant, destination therapy, or to recovery, providing either pulsatile or nonpulsatile support. Because of the increasing frequency of left ventricular assist device utilization and the improved short-term and long-term survival after placement, there has been a parallel increase in the radiologic imaging of patients with these devices, mandating radiologists' awareness of the manifestations of common complications, including infection, thrombosis and embolism, cannula obstruction, hemorrhage, and complications of adjacent vessels and viscera, all of which will be discussed in this pictorial essay.

Ventricular assist device-related infections

Heart failure is a leading cause of death in developed nations despite medical management. Cardiac transplantation is a potentially lifesaving intervention for approximately 4000 advanced heart failure patients per year; however, the demand for donor hearts far exceeds the supply. Ventricular assist devices provide temporary support for patients with severe heart failure until myocardial recovery occurs or a donor heart becomes available. For those ineligible for transplantation, ventricular assist devices may be used permanently and have demonstrated reduced mortality and an improved quality of life compared with continued medical therapy. Nonetheless, these devices are under-used, in part due to the frequency of complications. Device-related infections are one of the most frequent sequelae of ventricular assist device placement and occur in 18-59% of cases. Infections can involve any part of the device and confer substantial morbidity and mortality. Here, we provide an introduction to ventricular assist devices, explore the nature and pathogenesis of ventricular assist device-related infections, discuss problems with diagnosis, and present treatment and prevention strategies.