Ann Thorac Surg 2001;72:263-264
© 2001 The Society of Thoracic Surgeons
Case report
Pseudoaneurysm after heart transplantation with history of LVAD driveline infection
Tadashi Omoto, MDa,
Kazutomo Minami, MD, PhDa,
Toshihiro Muramatsu, MDb,
Shunei Kyo, MDb,
Reiner Körfer, MDa
a Department of Thoracic Cardiovascular Surgery, Heart Center North Rhine-Westphalia, Ruhr University of Bochum, Bad Oeynhausen, Germany
b First Department of Surgery, Saitama Medical School, Saitama, Japan
Accepted for publication May 3, 2000.
Address reprint requests to Dr Omoto, Department of Thoracic Cardiovascular Surgery, Heart Center North Rhine-Westphalia, Ruhr University of Bochum, Georgstrasse 11, D-32545 Bad Oeynhausen, Germany
e-mail: omoto{at}kddnet.de
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Abstract
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An infective complication of the aorta is a potential cause of early and late mortality after heart transplantation. We report the case of a 21-year-old male cardiac transplant patient in whom a pseudoaneurysm of the recipient site of ascending aorta coincided with the site of the outflow prosthesis of a preexisting left ventricular assist device; this condition developed 9 months after transplantation.
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Introduction
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During the last decade, left ventricular assist devices (LVAD) have been used to support the circulation as a bridge to transplantation. Infection is a major complication associated with use of these devices, and it presents some potential problems after heart transplantation.
The patient was a 21-year-old man who had undergone a heart transplant for dilated cardiomyopathy. Before transplantation, the patient had received implantation of a TCI HeartMate (Thermo Cardiosystems Inc, Woburn, MA) LVAD at Saitama Medical School in Japan. After 142 days of LVAD support, the patient required emergent device removal because of driveline infection with positive blood culture, identified as Staphylococcus aureus. The postoperative course after device removal was uneventful, with negative blood cultures; 3 months later, the patient underwent heart transplantation at Heart Center North Rhine-Westphalia in Germny. The aortic suture was below the site of the outflow prosthesis of the LVAD, because there was tight adhesion of tissues around the ascending aorta. Immunosuppressive therapy with predonine, azathioprine, and cyclosporine was initiated after transplantation. Repeated endomyocardial biopsies during the patient’s remaining hospitalization did not show any episodes of rejection.
Seven months after transplantation, the patient was febrile with positive blood culture (S aureus); however, the location of infection could not be ascertained. The patient was effectively treated with vancomycin. Nine months after transplantation, the patient was again febrile with positive blood culture (S aureus), and he underwent a number of diagnostic tests in an effort to locate the source of infection. An angiogram of the aortic root (Fig 1) disclosed a large mass in the anterior mediastinum, which was identified as a pseudoaneurysm of the ascending aorta distal to the aortic anastomosis.
The patient underwent reoperation for excision of the pseudoaneurysm and for repair of the ascending aorta. Cardiopulmonary bypass was initiated through femoral artery cannulation and right atrial drainage. The patient was cooled to 20°C, and circulatory arrest was begun. The pseudoaneurysm was resected and replaced by an aortic homograft 4 cm in diameter. Mediastinal tissue was debrided and irrigated; the chest was closed, with a percutaneous irrigation and drainage system in place for continual instillation of povidone-iodine to reduce residual bacterial contamination.
The intraoperative tissue culture was positive for S aureus, and vancomycin was administered. Immediately after the operation, the patient suffered from left hemiparesis, diagnosed as multiple posterocerebellar infarction. Cyclosporine was replaced by Prograf in the immunosuppressive therapy because of suspicion of graft rejection. A postoperative angiogram showed normal findings of graft heart/aortic homograft/host ascending aorta continuation (Fig 2). The patient was discharged 2 months after the operation, and he is alive and well 18 months after transplantation.
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Fig 2. Postoperative view: normal finding of graft heart/aortic homograft/host ascending continuation.
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Comment
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The case has illustrated a pitfall for heart transplantation of patients with implanted LVADs. Aortic complication after heart transplantation is rare, but it poses high morbidity and mortality [1–3]. There is a marked difference in diameter and compliance between donor and recipient aortas in most of cases, and the aortic suture line has been shown to be the most frequent site of aortic complication. In patients with mediastinitis with inflammatory edema of tissues, pressure stress favors the formation of a pseudoaneurysm at anastomosis. The suture line of the outflow prosthesis of the LVAD also has the potential to cause aneurysm formation after transplantation. Infection occurs in 50% of heart transplant patients who received LVADs as a bridge to transplantation [4, 5] and in 50% of heart transplant patients who had received LVADs previously [6, 7]. There is a substantial dilemma as to the site of aortic anastomosis when there is tight adhesion of the tissues around the ascending aorta due to the previous operation; however, if there is some history of LVAD infection, the site of the inflow cannula should also be resected, and the aortic anastomosis should be performed at a more distal location. There should be some discussion regarding whether the aortic homograft should have been replaced by end to end anastomosis or by partial patchplasty. In the case presented here, there was a major size mismatch between the donor aorta, the homograft, and the recipient aorta. The patchplasty was selected to reduce the pressure stress on the suture line.
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References
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Koyanagi T., Minami K., Tenderich G., et al. Thoracic and cardiovascular interventions after orthotopic heart transplantation. Ann Thorac Surg 1999;67:1350-1354.[Abstract/Free Full Text]
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Defraigne J.O., Vahdat O., Lavigne J.P., Demoulin J.C., Limet R. Aneurysm of the ascending aorta after cardiac transplantation. Ann Thorac Surg 1992;54:983-984.[Abstract]
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Oz M.C., Argenziano M., Catanese K.A., et al. Bridge experience with long term implantable left ventricular assist device: are they an alternative to transplantation?. Circulation 1997;95:1844-1852.[Abstract/Free Full Text]
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Massad M.G., McCarthy P.M., Smedira N.G., et al. Does successful bridging with the implantable left ventricular assist device affect cardiac transplantation outcome?. J Thorac Cardiovasc Surg 1996;112:1275-1283.[Abstract/Free Full Text]
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Masters R.G., Hendry P.J., Davies R.A., et al. Cardiac transplantation after mechanical circulatory support: a Canadian perspective. Ann Thorac Surg 1996;61:1734-1739.[Abstract/Free Full Text]
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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]
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Abstract
Introduction
