Gastric volvulus after ventricular assist device explantation and cardiac transplantation

Diaphragmatic herniation has been recognized as a complication of unrepaired diaphragmatic defects after left ventricular assist device explantation and cardiac transplantation. We believe this to be the 1st report of diaphragmatic herniation that resulted in gastric volvulus in a cardiac transplant recipient. The presentation, diagnosis, and treatment of this potentially fatal condition are discussed herein. Nine months after removal of a Thoratec HeartMate® II left ventricular assist device and orthotopic cardiac transplantation, the patient presented with intermittent upper abdominal and lower chest discomfort of 3 weeks' duration. Physical examination was notable for fullness in the upper abdomen. Plain radiographs and computed tomographic scans of the chest and abdomen without contrast were unexceptional. Two weeks later, the patient's pain began to worsen rapidly, and an upper gastrointestinal barium study revealed partial herniation of the stomach into the chest and omento-axial gastric volvulus without luminal obstruction. The patient underwent uncomplicated laparotomy for repair of the diaphragmatic defect and reduction of the herniated stomach. This case highlights the need for increased awareness of diaphragmatic herniation as a complication of unrepaired diaphragmatic defects so that diagnosis is not delayed, and underscores the importance of primary repair of all such defects to prevent future complications.