Joshua Sixon
University of Miami- JFK Medical Center
Atlantis, Florida
Disclosure information not submitted.
Title: New-Onset Hemidiaphragm Paralysis in a Patient Post-LVAD Implantation: A Novel Complication
Introduction: Mechanical circulatory assist devices such as left ventricular assist device (LVAD) are increasingly utilized in advanced heart failure as bridge to heart transplant or as destination therapy. Known complications of LVAD implantation include bleeding, post-operative infection, and pump thrombosis. We discuss the case of a patient with new-onset elevated right hemidiaphragm after LVAD placement.
Description: 32-year-old female with non-ischemic cardiomyopathy with left ventricular ejection fraction (LVEF) of 15%, pulmonary hypertension with right ventricular dysfunction, diabetes mellitus, morbid obesity, and polysubstance use presents for 1 day of shortness of breath, orthopnea, and leg swelling. Patient has been inotrope-dependent for 6 months and reports medication compliance. Initial chest x-ray (CXR) unremarkable. Echocardiogram showed LVEF of 25% with diffuse hypokinesis. Right heart catheterization showed low cardiac index of 2.04 L/min/m² while on milrinone. Multidisciplinary team of heart failure, pulmonology, psychiatry, and palliative care consulted for LVAD evaluation as destination therapy (not a transplant candidate due to morbid obesity). LVAD placed (Heartmate 3). Patient started on inotropes and monitored in ICU on mechanical ventilation. The next day, she developed respiratory distress, fever, and leukocytosis. CXR showed right upper lobe opacity. Empiric cefepime started; cultures drawn. Bronchoscopy done with bronchoalveolar lavage. Patient improved and extubated the next day to BiPAP. Repeat CXR showed elevated right hemidiaphragm. Fluoroscopic sniff test demonstrated elevated right hemidiaphragm with restricted motion during inspiration and expiration. Incentive spirometry and flutter valve encouraged. Patient improved, was weaned off inotropes, and discharged home on chronic heart failure medications.
Discussion: As prevalence of heart failure rises with the aging population, more novel complications of LVAD will likely be uncovered. In our patient, it is difficult to establish causality between LVAD placement and development of hemidiaphragm. However, no other factors from this case were thought to contribute to this occurrence. More research is required to better understand potential complications of LVAD implantation, either as a bridge to transplant or as destination therapy.