Chief Complaint : 59 year old male presented to the ED with left sided chest pain for one day.
History of Present Illness : The patient had a history of non-ischemic cardiomyopathy and underwent insertion of a left ventricular assist device (LVAD) in 2018. He subsequently had recurrent infections at the operative site leading to sepsis. In late 2020, the LVAD was explanted. He continued to have recurrent infections and modest hemorrhage from the chest wall wound, requiring four hospital admissions between 2020-22. The patient’s most recent admission was two months prior to presentation when he developed an infection of the LVAD pump pocket. He underwent wound debridement and was discharged with a wound vac in place.
On the day of presentation, the patient’s rehabilitation facility changed his wound vac and noted bleeding from the chest wall wound. The patient was tachycardic and normotensive. EMS controlled the bleeding with pressure. On arrival the patient reported severe throbbing chest pain at the wound site and chronic bleeding from the wound.
Pertinent Physical Exam: He was afebrile with a heart of 116, blood pressure of 103/57 mm Hg, respiratory rate of 27, and oxygen saturation of 95% on room air. He was overall well appearing and alert. After removal of the pressure dressing, scant hemorrhage with clots was noted from the wound on his chest wall (see attached image). His heart exam was notable tachycardic but regular rhythm without murmurs, rubs, or gallops. His lungs were clear to auscultation. His capillary refill was 2 seconds, and his skin was warm and well perfused.
Pertinent Laboratory Data: His electrocardiogram revealed a paced rhythm. His white blood cell count was 21 k/uL, and his hemoglobin was 8 g/dL. His chest radiograph showed no consolidation or pneumothorax.
Case Discussion: Given the prior infections and leukocytosis, there was concern for a recurrent infection or hematoma formation. The patient was taken for CT, and while there his bleeding worsened significantly. He returned to the ED and was hypotensive with a blood pressure of 84/42. He bled through a pressure dressing, and his FAST exam did not demonstrate any free fluid in the abdomen. The patient’s chest CT scan (see attached images) revealed perforation of the apex of the left ventricle filling a pseudoaneurysm with a fistula tract to the chest wall. Tranexamic acid was administered, and cardiothoracic surgery was consulted emergently. The patient was emergently transfused with blood products and taken to the operating room for repair. He suffered a cardiac arrest during the operation and was placed on extracorporeal membrane oxygenation life support. At the behest of the patient’s family, this was withdrawn after several days, and the patient died.
Bleeding is a common complication following LVAD insertion, occurring in approximately 20% of patients. However, it is typically in the immediate post-operative period or later from the GI tract. To our knowledge, this is the first case report of profound hemorrhage following explantation of a LVAD. The recurrent infections at the post-operative site potentially allowed for the pseudoaneurysm to form When the fistula formed to the chest wall this led to exsanguination and death.
