HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Boulos Asfour Dieter Hammel Christoph Schmidt Hans H. Scheld Christof Schmid Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tjan, T. D.T. Articles by Schmid, C. Search for Related Content PubMed PubMed Citation Articles by Tjan, T. D.T. Articles by Schmid, C.

Ann Thorac Surg 2000;70:538-541
© 2000 The Society of Thoracic Surgeons

---

Original articles: cardiovascular

Wound complications after left ventricular assist device implantation

^a Departments of Department of Cardiothoracic Surgery, Westfälische Wilhelms-University, Münster, Germany
^b Department of Anesthesia and Operative Intensive Care Medicine, Westfälische Wilhelms-University, Münster, GermanyDEU

Address reprint requests to Dr Schmid, Department of Cardiothoracic Surgery, Westfälische Wilhelms-University, Albert-Schweitzer-Str 33, 48149 Münster, Germany
e-mail: schmid{at}uni-muenster.de

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Wound necrosis and infection pose a tremendous risk for patients with left ventricular assist devices.

Methods. We analyzed our database of patients with left ventricular assist devices for those who developed wound dehiscence and concomitant infection after left ventricular assist device implantation.

Results. Three of our 66 patients (4.5%) with implantable ventricular assist devices had had severe wound complications with necrosis of the abdominal or thoracic wall uncovering part of the device. The predominant impact on the development of these complications was presumably related to multiple surgical interventions on the same site.

Conclusions. Nevertheless, these patients can recover and undergo successful heart transplantation if adequately managed.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
During recent years, numerous institutions have introduced left ventricular assist devices (LVADs) as a therapeutic option in cases of acute or end-stage cardiac failure mainly as a bridge to heart transplantation. Meanwhile, mean support intervals are exceeding 100 days in many cardiosurgical centers, and the cumulative experience with LVADs comprises some hundred patient-years [1]. Moreover, a significant subgroup of patients with LVADs demonstrates remarkable recovery and is able to be treated on an outpatient basis [2].

However, LVADs are far from being perfect. Severe complications may still jeopardize the patient’s outcome and quality of life [3–5]. Infection, ie, device contamination, and bacteremia are the most frequent and often serious sequelae after implantation of a long-term mechanical assist device. Some patients have wound necrosis and concomitant infection, which pose a tremendous therapeutic challenge to physicians and surgeons. This report focuses on our experience with this small subset of patients with LVADs who experienced wound dehiscence uncovering part of the mechanical device.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Since initiation of our LVAD program in 1993, 54 patients were provided with a portable Novacor N100 (Baxter Healthcare, Oakland, CA) and 12 with a HeartMate VE (Thermo Cardiosystems, Woburn, MA) LVAD. Except for the very early experience, all LVADs were implanted with the heart beating during extracorporeal circulation as previously reported [6]. The pump chamber was placed into the posterior sheath of the left rectus muscle. In small patients, the right rectal sheath was also detached to gain more space for the pump. Anticoagulation protocols varied with time, and consisted of intravenous heparin, followed by the oral anticoagulant phenprocoumon and platelet inhibitors.

All patients were provided with prophylactic antibiotic treatment using modern cephalosporins until all wound drains were removed. Drive line exits were treated with polyvinylpyrrolidone-iodine ointment and taped with sterile dressings until wound healing occurred. In case of suspected infection, ie, sustained febrile or subfebrile temperatures, leukocytosis, and wound secretion, an intensive microbiologic examination including daily blood cultures and cotton swabs was initiated, and antibiotic treatment was adjusted to the microbiologic findings. In patients with postoperative complications necessitating redo sternotomy or temporary open-chest treatment, vancomycin was added early in a preemptive manner.

The medical records of the patients with severe wound complications were analyzed with regard to patient demographics, putative risk factors, treatment, and outcome.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Three of our 66 patients (4.5%) with implantable VADs experienced severe wound complications with necrosis of the abdominal or thoracic wall. These patients were young, ranging in age from 23 to 47 years, and had a normal body mass index. Two of them had diabetes mellitus, but none had a prior infection. The patients presented with manifest or imminent multiorgan failure and underwent LVAD placement on an emergency or urgent basis (Table 1 and Table 2).

Patient 2, who was 47 years old (167 cm, 68 kg), suffered from postcardiotomy failure after coronary artery bypass grafting, which could not be alleviated by insertion of an intraaortic balloon pump in May 1997. With the patient being in multiorgan failure, emergency implantation of a Novacor N100 was performed. Redo thoracotomy for ongoing drainage losses were necessary on postoperative days 1 and 3. Furthermore, surgical revisions of the device pocket followed on days 5 and 16. The patient had a slow recovery with development of a chronically oozing fistula in the area of the device pocket. Finally, the patient was discharged on postimplant day 94. During the follow-up, the fistula enlarged, and necrosis of the thoracic wall developed. A large defect uncovered the pump housing and the drive line, and the patient had to be rehospitalized and treated with antibiotics (Fig 1). Microbiologic investigation revealed contamination with staphylococci and Escherichia coli. Later, the patient became colonized by fungi and experienced consecutive fungus embolism in both femoral arteries on days 138 and 261. After the last setback, the patient was listed for special urgency transplantation and successfully received a donor organ on day 272.

View larger version (89K): [in this window] [in a new window]   Fig 1. Severe wound infection of the lateral wall uncovering the pump chamber and drive line.

View larger version (125K): [in this window] [in a new window]   Fig 2. Severe median wound infection with a visible outflow conduit.

	Comment

Top Abstract Introduction Material and methods Results Comment References

In slim and small patients, it may be rather difficult to create an appropriate device pocket in the posterior sheath of the left rectal muscle. Even if the pocket is enlarged across the linea alba to the right side, considerable tension may arise when closing the median wound. Hence, all efforts should be directed to insert the pump chamber in a manner that allows closing the wound without unacceptable tension. If necessary, the diaphragm has to be partially detached, or the abdomen relieved from ascites. Intraperitoneal placement of the pump chamber has been shown to reduce the incidence of infectious complications, but has been abandoned in most institutions as this often resulted in compression of the stomach and intestines [10–12].

Recurrent trauma to the wound is sometimes unavoidable. In patients undergoing LVAD placement on an emergency basis after postcardiotomy heart failure or even after extracorporeal membrane oxygenation, the coagulation system is severely deranged, sufficient hemostasis is difficult to achieve, and several surgical revisions may be required. Sometimes mediastinal packing with surgical towels and open-chest treatment are necessary for a few days, significantly increasing the risk of mediastinitis. If a localized hematoma of the device pocket develops, it may be advisable to do the revision through a new access to not further jeopardize healing of the median sternotomy wound.

Treatment of the resulting inflammatory wound dehiscence with uncovering part of the mechanical device consists of antibiotic and surgical measures and is extremely difficult. The outcome is often uncertain. A small oozing fistula is usually treated nonsurgically as long as the patient is not severely compromised as it is well known from patients with graft infection after operation for aortic aneurysms that long-term and even lifelong antibiotic treatment is able to control the spread of microorganisms [13]. If extensive necrosis is present, careful removal of the necrotic tissue is essential to eradicate infection. However, trimming the wound edges will enlarge the defect and pose additional tension on a closed wound. In our 3 patients, wound necrosis without debridement resulted in an uncovered pump chamber and outflow conduit, without a possibility of readapting the wound edges. Because plastic surgical techniques were considered to be too hazardous, we decided to leave the wounds open, allowing drainage of infectious secretions, to reduce the risk of systemic infection caused by abscess formation. As it is well known from reconstructive bone operations, secondary wound healing may even occur in the presence of metallic implants, but it is limited by the size of the defect. In trauma operations, extensive debridement and lavage are common and highly efficient. In our patients, the wounds became clean and also smaller with time, but did not close. We assume that infection could not be eliminated because of colonization of the large amount of foreign material. Yet, the patients recovered well and could even be partially treated on an outpatient basis.

The duration of mechanical support in these cases significantly exceeded the average support interval in our institution by far. Although our normal patients with LVADs are on the device for 3 to 6 months (mean, 126 ± 108 days), the 3 patients reported here were on mechanical support for 272 to 421 days. This demonstrates that even under such difficult circumstances, successful long-term support and heart transplantation are possible. No doubt, unusually severe adhesions are encountered during the transplant procedure, rendering hemostasis difficult. But as the infectious focus is eliminated in total, the postoperative risk seems only mildly increased. Only closure of the wound involved may become a surgical challenge.

In conclusion, severe necrotic wound infections may develop after LVAD placement. If adequately managed, these patients will recover and can undergo heart transplantation with an acceptable risk.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Goldstein D.J., Oz M.C., Rose E.A. Implantable left ventricular assist devices. N Engl J Med 1998;339:1522-1533.[Free Full Text]
2. Schmid C, Hammel D, Deng MC, et al. Ambulatory care of patients with left ventricular assist devices. Circulation 1999;100 (19 Suppl): II224–8.
3. Quaini E., Pavie A., Chieco S., Mambrito B. The Concerted Action ‘Heart’ European registry on clinical application of mechanical circulatory support systems. Eur J Cardiothorac Surg 1997;11:182-188.[Abstract]
4. Kormos R.L., Borovetz H.S., Gasior T., et al. Experience with univentricular support in mortally ill cardiac transplant candidates. Ann Thorac Surg 1990;49:261-272.[Abstract]
5. Schmid C., Weyand M., Nabavi D.G., et al. Cerebral and systemic embolization during left ventricular support with the Novacor N100 device. Ann Thorac Surg 1998;65:1703-1710.[Abstract/Free Full Text]
6. Scheld H.H., Hammel D., Schmid C., et al. Beating heart implantation of a wearable Novacor left-ventricular assist device. Thorac Cardiovasc Surg 1996;44:62-66.[Medline]
7. Argenziano M., Catanese K.A., Moazami N., et al. The influence of infection on survival and successful transplantation in patients with left ventricular assist devices. J Heart Lung Transplant 1997;16:822-831.[Medline]
8. Herrmann M., Weyand M., Greshake B., et al. Left ventricular assist device infection is associated with increased mortality but is not a contraindication to transplantation. Circulation 1997;95:814-817.[Abstract/Free Full Text]
9. Fischer S., Trenholme G., Costanzo M., Piccione W. Infectious complications in left ventricular assist device recipients. Clin Infect Dis 1997;24:18-23.[Medline]
10. Arabia F.A., Smith R.G., Rose D.S., Arzouman D.A., Sethi G.K., Copeland J.G. Success rates of long-term circulatory assist devices used currently for bridge to heart transplantation. ASAIO J 1996;42:M542-M546.[Medline]
11. Radovancevic B., Frazier O.H., Duncan J.M. Implantation technique for the HeartMate left ventricular assist device. J Card Surg 1992;7:203-207.[Medline]
12. Oz M.C., Goldstein D.J., Rose E.A. Preperitoneal placement of ventricular assist devices. J Card Surg 1995;10:288-294.[Medline]
13. Coselli J., Crawford E., Williams T.J., et al. Treatment of postoperative infection of ascending aorta and transverse aortic arch, including use of viable omentum and muscle flaps. Ann Thorac Surg 1990;50:868-881.[Abstract]

This article has been cited by other articles:

				E. D. Feller, E. N. Sorensen, M. Haddad, R. N. Pierson, F. L. Johnson, J. M. Brown, and B. P. Griffith Clinical Outcomes Are Similar in Pulsatile and Nonpulsatile Left Ventricular Assist Device Recipients Ann. Thorac. Surg., March 1, 2007; 83(3): 1082 - 1088. [Abstract] [Full Text] [PDF]

				C. Schmid, M. Schneider, C. Etz, and H. H. Scheld Heart Transplantation in a Patient With a Left Ventricular Assist Device and Methicillin-Resistant Staphylococcus Aureus Infection Ann. Thorac. Surg., November 1, 2004; 78(5): 1820 - 1821. [Abstract] [Full Text] [PDF]

				W. L. Holman, B. K. Rayburn, D. C. McGiffin, B. A. Foley, R. L. Benza, R. C. Bourge, L. J. Pinderski, and J. K. Kirklin Infection in ventricular assist devices: prevention and treatment Ann. Thorac. Surg., June 1, 2003; 75(90060): S48 - 57. [Abstract] [Full Text] [PDF]

				G. Matsumiya, M. Nishimura, Y. Miyamoto, Y. Sawa, and H. Matsuda Successful treatment of Novacor pump pocket infection by omental transposition Ann. Thorac. Surg., January 1, 2003; 75(1): 287 - 288. [Abstract] [Full Text] [PDF]

				S. M. Gordon, S. K. Schmitt, M. Jacobs, N. M. Smedira, M. Goormastic, M. K. Banbury, M. Yeager, J. Serkey, K. Hoercher, and P. M. McCarthy Nosocomial bloodstream infections in patients with implantable left ventricular assist devices Ann. Thorac. Surg., September 1, 2001; 72(3): 725 - 730. [Abstract] [Full Text] [PDF]

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): Boulos Asfour Dieter Hammel Christoph Schmidt Hans H. Scheld Christof Schmid Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tjan, T. D.T. Articles by Schmid, C. Search for Related Content PubMed PubMed Citation Articles by Tjan, T. D.T. Articles by Schmid, C.