Radiological Category Chest Imaging Principal Modality 1 Plain

Radiological Category: Chest Imaging Principal Modality (1): Plain Film Principal Modality (2): None Case Report 0939 Submitted by: Logan Boatman, M. D. Faculty reviewer: Emma Ferguson, M. D Date accepted: 15 January 2013

Case History Nurse calls about a 54 year-old male with “heart surgery a few days ago” and “chest pain”. There is no other history available.

Radiological Presentations Baseline chest radiograph

Radiological Presentations

Radiological Presentations Follow-up chest radiograph obtained soon after the baseline CXR

Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. • Iatrogenic pneumocardia • Ventricular assist device, unsatisfactory placement • Ventricular assist device, satisfactory placement • Total artificial heart, unsatisfactory placement • Total artificial heart, satisfactory placement

Findings and Differentials Findings: - Curvilinear lucencies overlying the right and left ventricles - 4 round radiodensities similar in appearance to artificial valves and in the expected position of the cardiac valves - Large bore tubes terminating along the inferior margins of the left and right ventricles - Chest tubes and other life support lines and tubes including an AICD - Airspace consolidation throughout most of the left lung and minimally in the right lower lobe Differentials: • Iatrogenic pneumocardia • Ventricular assist device, unsatisfactory placement • Ventricular assist device, satisfactory placement • Total artificial heart, unsatisfactory placement • Total artificial heart, satisfactory placement

Discussion Pneumocardia is rarely seen but can be caused by recent heart surgery. Additional causes include air emboli and failed pericardiocentesis. The large amount of air seen in this case makes pneumocardia extremely unlikely as it would not be compatible with life. Ventricular assist devices (VAD) and total artificial hearts (TAH) have seen significant increased use in the past few years. Both are used as bridging devices prior to heart transplant. There a number of known complications associated with VADs including hemopericardium, hemoperitoneum, infection, thrombosis of the device itself or downstream thromboembolism, pneumothorax, and hemothorax. Complications of the TAH are similar but are less well documented owing to fewer numbers of patients.

Discussion There are currently 2 FDA approved TAHs, the Syn. Cardia (as in this case and pictured) and the Abio. Cor. During its 10 year clinical trials, the Syn. Cardia had a 79% (95% CI of 68 -87%) survival to cardiac transplant. The highest of any TAH or VAD.

Discussion A VAD is a mechanical pump that can either supplement or replace cardiac function. Where TAHs require removal of the native heart, VADs are implanted into the right, left, or both ventricles. VADs may also be used as bridge devices for cardiac transplant, but in some cases, native cardiac output improves such that the VAD may be removed without transplant.

Diagnosis Total artificial heart, satisfactory placement

References Green D. Evaluation of LV Assistance Devices. www. statdx. com. Knisely BL et al: Imaging of ventricular assist devices and their complications. Am J Roentgenol. 1997 Aug; 169(2): 385 -91 Copeland JG et al: Cardiac Replacement with a Total Artificial Heart as a Bridge to Transplantation. New England Journal of Medicine. 2004 Aug; 351: 859 -867 Tichauer M et al: Right Ventricular Pneumocardia Secondary to Hepatic Abscesses. Case Rep Gastroenterol. 2010 Nov; 4: 498 -501 Diagrams obtained from Syn. Cardia Systems Inc. and wikipedia. org under the Creative Commons license.