Colostomy Reversal in a Patient with an LVAD: A Case Report

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Introduction Patients with existing Left Ventricular Assist Device (LVAD) who undergo non-cardiac surgery have a 9% risk of surgical site infection and up to a 44% chance of peri- and post-operative bleeding. This, along with the hemodynamic compromise of advanced heart failure, often makes LVAD patients prohibitively high risk for non-emergent surgeries. We present a successful case of an LVAD implanted into a patient with prior colostomy, who then later underwent a technically difficult colostomy reversal and parastomal hernia repair, without any of the aforementioned complications. Case Report A 44-year-old male with a history of non-ischemic cardiomyopathy (LVEF 20%) subsequently suffered perforated diverticulitis which was treated with a sigmoid colon resection with end colostomy. Later that year, he required LVAD (HeartMate 3™ Abbott) placement for cardiogenic shock requiring chronic inotropic support. Prior to his LVAD placement, colostomy reversal was considered to reduce the risk of post-operative LVAD driveline infection. Ultimately, colostomy reversal was deferred due to concern that a colorectal anastomosis may leak due to poor perfusion. However, he then developed a parastomal hernia with loss of domain which hindered colostomy care. Because he was weaned off inotropes and had clinically improved after his LVAD placement, it was felt he would be hemodynamically stable to tolerate colostomy reversal and subsequent parastomal hernia repair. His anticoagulation with warfarin was held for bridging enoxaparin one week before surgery. The colostomy site fascial defect was closed primarily and a sublay of synthetic mesh was placed. The surgical dissection at the old colostomy site was done to ensure there was adequate distance between the surgical field and LVAD driveline. The presence of the LVAD driveline along the right abdominal wall limited the ability to perform a right sided component separation but it was done on the left side to gain intra-abdominal domain. He remained stable during and after the procedure. Warfarin was re-started post-operative day one. Summary This demonstrates feasibility to receive an LVAD with an existing colostomy, despite risk of infection. It also highlights that patients with an LVAD can undergo colostomy reversal and parastomal hernia repair, despite risk of poor anastomosis healing, bleeding, subcutaneous infection, and LVAD driveline infection.