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Ann Thorac Surg 2002;74:1267-1268
© 2002 The Society of Thoracic Surgeons

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How to do it

Surgical management of Novacor drive-line exit site infections

^a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
^b Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
^c Division of Nursing Services, Barnes-Jewish Hospital, St. Louis, Missouri, USA

Accepted for publication April 30, 2002.

* Address reprint requests to Dr Pasque, Division of Cardiothoracic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 3108 Queeny Tower, St. Louis, MO 63110 USA
e-mail: pasquem{at}msnotes.wustl.edu

	Abstract

Top Abstract Introduction Technique Comment Acknowledgments

 
Implantable left ventricular assist device (LVAD) drive-line exit site infection, an expected consequence of currently available device use, continues to be a significant limiting factor in long-term support. We theorize that the mechanism behind the establishment of the most chronic exit site infections involves a shearing torsion injury that disrupts the tissue adherence interface with the drive-line. The resulting neo-epithelialized drainage tract prevents permanent clearance of the infection with antibiotics alone. The proposed treatment strategy of established infections involves aggressive surgical excision of the involved exit site.

	Introduction

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Treatment of patients with end-stage heart failure for the immediate future will involve devices, such as the Novacor (World Heart Corporation, Ottawa, Ontario, Canada) left ventricular assist device (LVAD), in which successful long-term use is dependent upon the appropriate extended management of drive-line exit sites.

	Technique

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We propose that drive-line trauma remains the most common initiator of drive-line exit site infections. This trauma usually takes the form of a shearing traction or torsion injury, commonly initiated by events such as dropping the controller and battery pack, leaving without picking up the controller and battery pack, or accidentally hooking the drive-line on a passing object. Certainly, all such trauma to the drive-line exit site cannot be prevented. Indeed, the goal of placing these devices is to allow patient mobility and the chance to live as normal a life as possible. However, exit site infection prevention strategies must involve not only careful sterile management of the exit site, but also patient education to minimize activities that may abnormally predispose drive-line trauma.

The shearing traction or torsion injury associated with drive-line exit site trauma results in a disruption of the adherent interface between the skin and subcutaneous tissues and the velour covering of the drive-line. This adherent interface normally inhibits the initiation of exit site infection as long as it remains intact. However, in the setting of significant trauma this adherence is disrupted to a variable degree depending upon the type of drive-line trauma. It was initially our belief that this sort of injury universally led to an associated infection. However, further experience has demonstrated that some of these interface disruptions are able to heal completely with circumferential readherence of the drive-line. Complete immobilization of the exit site may be critical in this process. In other words, if the exit site continues to be subjected to the normal little tugs and twists of everyday use, the unbound tissue continues to slide back and forth over the drive-line and is never allowed readherence to it. The result is the formation of a neo-epithelialized surface that resists further adherence. We propose that once this occurs, the patient is left with a nonhealing tract adjacent to the drive-line, which supplies the ideal environment for the initiation of resistant infection. It is our feeling that this nonhealing, chronically infected tract is nearly impossible to eliminate without surgical intervention. In addition, the body’s natural tendency to seal the opening of the exit site with proteinaceous material further predisposes toward extension of the infection inward toward the implanted pump itself.

LVAD patients should be educated to notify the device management team immediately upon identification of significant exit site trauma. Steps should be taken to further immobilize the exit site. This usually involves restriction of patient activity as well as augmented drive-line stabilization over a gauze roll using additional tape, sutures or stoma-adhesive devices to insure drive-line immobility. A short course of antibiotics may be helpful, but may also predispose growth of resistant organisms. The length of time for guarded immobilization is dependent on the continued close scrutiny by the management team.

Unfortunately, the first physician notification of an exit site problem is often long after the inciting trauma, when the patient presents with complaints of localized pain over the exit site. Typically at this point a drive-line exit site infection is well underway, and a tract has already been established. Once this has occurred, we propose implementation of an aggressive surgical algorithm. This aggressive approach is based on our past observance of virtually consistent failure of isolated antibiotic treatment and watchful waiting. These measures may temporarily delay extension of the infection, but can rarely be expected to eliminate the problem.

We prepare the exit site for excision with a course of intravenous antibiotics directed at known or suspected pathogens. Reduction in the size of the surrounding tissue excision can be obtained by controlling the cellulitis before surgical intervention. During the course of antibiotic therapy, a nuclear medicine labeled white blood cell scan is obtained. In our experience these scans have been extraordinarily accurate in preoperative prediction of tract anatomy, and therefore in the extent of exit site excision that will be required. An isolated hot spot at the exit site alone suggests that a very limited excision will suffice. A hot spot at the exit site with a small trail of activity extending up the drive-line, unfortunately suggests that a more extensive exit site excision may be required to reach a circumferentially adherent area of the drive-line. Worse yet, a trail of activity up to and involving the implanted device itself suggests that it may be too late for localized surgical intervention.

The primary strategy behind the proposed excision of the exit site is to completely eliminate the neoepithelialized tract. Therefore the surgical goal is to excise the exit site back to a place on the drive-line where the tissues are clearly adherent circumferentially. The extent of the neoepithelialized tract must be determined as the initial step of the operation. This is accomplished by passing a soft, small caliber red rubber tube gently up the tract to see how far it extends up the drive-line. If the tract is limited to a short distance, routine exit site excision is carried out to the level of circumferential adherence of tissue to the drive-line. The wound is gently packed with gauze after hemostasis is obtained, and the drive-line is maximally immobilized over a gauze roll and secured distally with a temporary skin suture and stoma-adhesive fixture. Maximal immobilization is continued until the tissue scars into a new exit site (Fig 1). In most cases, relatively rapid contraction of the wound around the immobilized drive-line occurs with continued adherence of the subcutaneous tissues to the drive-line until the next drive-line trauma.

View larger version (79K): [in this window] [in a new window]   Fig 1. This postoperative follow-up photograph demonstrates that the Novacor left ventricular assist device drive-line exit site has been excised and is slowly contracting back down around the circumferentially adherent drive-line tissue interface.

We have performed drive-line exit site surgical excision seven times in 4 patients after Novacor placement. In all cases in which drive-line exit site excision was complete (in which the entire tract could be excised), the drive-line exit site healed completely. Re-excisions were necessary only after documented recurrent drive-line trauma resulted in recurrent tract development and reinfection. Two excisions were incomplete secondary to tract extension to within two inches of the pump pocket. As described previously, a small drain was used to control the unexcised tract. The drive-line infections in these 2 patients were controlled for 4 and 14 months, respectively.

	Comment

Top Abstract Introduction Technique Comment Acknowledgments

 
The control of LVAD drive-line exit site infections is critical if long-term support with currently available devices is desired. We would propose that a plan of antibiotics and watchful waiting alone is doomed to failure in most cases in which a chronic neo-epithelialized tract has become established after drive-line trauma. A strategy using a course of intravenous antibiotics followed by aggressive surgical exit site excision, back to a level of circumferential adherence of the tissue to the drive-line, has allowed us to extend the effective lifespan of these devices in this critically ill population.

	Acknowledgments

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We acknowledge the support of the Department of Anesthesiology and the incredible operating room and intensive care nursing, perfusion, and ancillary staffs at Barnes-Jewish Hospital, St. Louis, Missouri.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Michael K. Pasque Stephen D. Cassivi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pasque, M. K. Articles by Rogers, J. G. Search for Related Content PubMed PubMed Citation Articles by Pasque, M. K. Articles by Rogers, J. G. Related Collections Mechanical Circulatory Assistance