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Ann Thorac Surg 1999;68:1080-1082
© 1999 The Society of Thoracic Surgeons

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Case Reports

Management of wound and left ventricular assist device pocket infection

^a Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
^b Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA

Address reprint requests to Dr Holman, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294-0007;
e-mail: wholman{at}holman.cvsr.uab.edu

	Abstract

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Our patient developed a wound infection that involved an implanted left ventricular assist device. At surgery, the pump was washed with a detergent-containing bacteriocidal solution, then antibiotic-impregnated polymethylmethacrylate beads were placed around the pump. The wound was revised using rectus muscle to cover the pump. The incisions have healed and the patient is now at home. She is on no systemic antibiotics and has no evidence of infection 11 months postoperatively.

	Introduction

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The use of ventricular assist devices (VADs) as a bridge to cardiac transplantation is an established therapy, and trials of these devices as permanent implants are now underway. Infection is recognized as an important complication of implanted VADs [1, 2]. This case report describes a patient with an implanted VAD, who developed a wound infection that involved the external surface of the pump. Wound revision, together with systemic and local antibiotics, resulted in good intermediate-term infection control. The surgical techniques used in this patient, including the implantation of antibiotic impregnated polymethylmethacrylate (PMMA) beads, are presented.

The patient is a 32-year-old woman with idiopathic dilated cardiomyopathy who received a HeartMate pneumatic left VAD (Thermo Cardiosystems, Inc, Woburn, MA) on December 18, 1996 as a bridge to transplantation. She subsequently developed a high titer of antibodies, and had numerous positive cross-matches. Efforts to diminish her antibody levels failed, although she had excellent rehabilitation. The patient awaited a donor heart at home until January 26, 1998, when she returned to the hospital because of a disruption at the connection of the drive line to the pump. The VAD was urgently replaced with a HeartMate vented electric left VAD. This operation was complicated by bleeding from a tear at the left ventricular apex. A left thoracotomy extension of the midline incision, which transected the internal thoracic artery, was required to adequately control this bleeding (Fig 1).

View larger version (27K): [in this window] [in a new window]   Fig 1. The position of the left VAD is shown relative to the rib cage and diaphragm. The vertical incision (dashed lines) required horizontal extension at the time of reoperation (solid line). The pump is in a preperitoneal pouch that was created at the time of the original implantation.

At surgery on March 9, 1998, the VAD pump was exposed without reopening the sternum. Fibrinous material from around the device was cultured. It grew Staphylococcus epidermidis and Pseudomonas aeruginosa. A bovine pericardial patch that rested between the VAD outflow cannula and the sternum was also removed. Culture of the patch showed S epidermidis.

The entire surface of the VAD and surrounding tissues, including the lower portion of the mediastinum, were washed using a pulsatile irrigating device (Pulsavac; Zimmer, Inc, Warsaw, IN) and 6 L of sterile saline containing 10 mL of Betadine soap (Becton-Dickinson, Franklin Lakes, NJ) per liter. The midline incision was extended to the pubis to expose the right rectus muscle. This muscle was mobilized and divided at the attachment to the pubis.

At this point, PMMA (Howmedica, Rutherford, NJ) beads, which contained 5 g of vancomycin and 2.4 g of tobramycin, were made by mixing the PMMA components and antibiotics together, then fashioning the paste into 5–7-mm beads, which were strung on malleable stainless steel wires. The 29 beads were placed around all surfaces of the VAD, the inflow conduit, and the outflow conduit. The rectus muscle, which was still attached to the costal margin and the superior epigastric artery, was rotated over the VAD in the region of the previous defect. The wound was closed over numerous drains, although tension on the skin precluded complete closure. The exposed portion of the rectus muscle remained viable postoperatively, and was subsequently covered with a skin graft.

The serum concentrations of vancomycin and tobramycin remained below therapeutic/toxic levels after implantation of the antibiotic impregnated beads, although the concentration of these antibiotics in the wound drainage was extremely high (tobramycin > 20 µg/mL, vancomycin > 50 µg/mL at 28 days postimplant). The drainage remained culture negative.

The patient was discharged from the hospital on intravenous nafcillin and ceftriaxone, which had been started postoperatively and were continued for 10 weeks. At the present time, the wound is well healed, the patient is living at home 70 miles from the hospital, her leukocyte count is normal, and she remains afebrile at 9 months after completing all antibiotic therapy.

	Comment

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Infection is an important problem for patients supported by VADs [1, 2]. Infection management will increase in importance as VADs are used as destination therapy rather than as a bridge to transplantation. The first report of antibiotic-impregnated PMMA therapy for a VAD pocket infection from McKeller and associates noted that there were several advantages of this method over previously used methods [3]. Extremely high local concentrations of antibiotics are generated in the region of infection while systemic absorption is low, thereby minimizing the adverse effects that might occur with high dose systemic antibiotic regimens [4]. Furthermore, the patient’s mobility is not impeded and care at home is feasible. In contrast, chronic irrigation of the infected area, which has been used successfully in other patients [1, 3], restricts mobility and precludes hospital discharge.

The patient described in the previous report [3] was transplanted 9 days after PMMA bead placement. In the present case, however, the patient is nearly 1 year out from PMMA bead placement, indicating that intermediate and possibly long-term infection control is possible using this method. Furthermore, the present case illustrates that outpatient management can be accomplished.

The use of antibiotic-impregnated PMMA beads originated with orthopedic surgeons, who used this method in patients with infected joint prostheses and chronic osteomyelitis. The results in these patients have been impressive. In multicenter trials, treatment failure with recurrent late infections have been noted in only 20% to 35% of patients 1 year or later after therapy, and the adverse effects of chronically implanted PMMA beads have been minimal [5].

There are several principles of therapy illustrated in this case that may prove useful in the management of similar patients. The wound was throughly debrided and cleaned with a detergent containing bactericidal solution before placing the beads. This is important for destroying, as completely as possible, the biofilm that forms on foreign surfaces and protects bacteria [6]. The PMMA beads were made with adequate amounts of antibiotics and were shaped as small spheres in order to optimize the elution of antibiotics. There are commercially fabricated gentamicin-impregnated PMMA beads that are optimized for antibiotic elution, but they are not available in the United States [7]. Thus, antibiotic impregnated beads must be made "from scratch," but with certain qualifications. Only single antibiotics or combinations of antibiotics that have been tested by others should be used. If vancomycin is chosen for the mixture, the PMMA should be kept as cool as possible as it cures to prevent denaturation of the antibiotic. This can be achieved by making small beads and separating them from one another in a cool room. After the beads are placed, the serum concentration of the antibiotic(s) used in the PMMA should be checked to be certain that systemic absorption remains below toxic levels. Antibiotic concentrations in the drainage should be checked to determine that bacteriocidal concentrations are eluting from the PMMA.

Ventricular assist device coverage should include muscle or omentum if at all possible. This tissue should be used to replace the scar that typically forms around a chronically implanted VAD. Capsular scar tissue is a barrier to the passage of systemic antibiotics and does not promote a host response to bacterial or fungal organisms. In this patient, the anterior portion of the pump was covered by muscle, however, the capsule was not totally excised and remained in contact with the posterior surface of the pump.

The use of antibiotic-impregnated PMMA beads has been criticized because it may lead to the selection of resistant organisms that could lead to recurrent infection. This problem, however, has not been noted in the orthopedic surgical literature. In light of this experience, and in view of the difficulty and expense in managing these patients by any other means, the use of antibiotic-impregnanted PMMA for VAD pocket infection seems worthwhile.

	References

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1. Holman W.L., Murrah C.P., Ferguson E.R., Bourge R.C., McGiffin D.C., Kirklin J.K. Infections during extended circulatory support. Ann Thorac Surg 1996;61:366-371.[Abstract/Free Full Text]
2. Fisher S.A., Trenholme G.M., Costanzo M.R., Piccione W., Jr Infectious complications in left ventricular assist device recipients. Clin Infect Dis 1997;24:18-23.[Abstract/Free Full Text]
3. McKeller S.H., Allred B.D., Marks J.D., et al. LVAD pocket infection controlled with antibiotic-impregnated polymethylmethacrylate beads. Ann Thorac Surg 1999;67:554-555.[Abstract/Free Full Text]
4. Henry S.L., Seligson D., Mangino P., Popham G.J. Antibiotic-impregnated beads. J Orthop Res 1991;20:242-247.
5. Blaha J.D., Nelson C.L., Frevert L.F., et al. The use of Septopal (polymethylmethacrylate beads with gentamicin) in the treatment of chronic osteomyelitis. Instr Course Lect 1990:509-514.
6. Anglen J., Apostoles P.S., Christensen G., Gainor B., Lane J. Removal of surface bacteria by irrigation. J Orthop Res 1996;14:251-254.[Medline]
7. Nelson C.L., Griffin F.M., Harrison B.H., Cooper R.E. In vitro elution characteristics of commercially and noncommerically prepared antibiotic PMMA beads. Clin Orthop 1992;284:303-309.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): William L. Holman David C. McGiffin James K. Kirklin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Holman, W. L. Articles by Kirklin, J. K. Search for Related Content PubMed PubMed Citation Articles by Holman, W. L. Articles by Kirklin, J. K.