Ann Thorac Surg 2003;75:287-288
© 2003 The Society of Thoracic Surgeons
Case report
Successful treatment of Novacor pump pocket infection by omental transposition
Goro Matsumiya, MD*a,
Motonobu Nishimura, MDa,
Yuji Miyamoto, MDa,
Yoshiki Sawa, MDa,
Hikaru Matsuda, MDa
a Department of Surgery, Division of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
Accepted for publication August 1, 2002.
* Address reprint requests to Dr Matsumiya, Department of Surgery, Osaka University Graduate School of Medicine (E1), 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
e-mail: matsumg{at}surg1.med.osaka-u.ac.jp
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Abstract
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Device-related infection remains a major factor restricting the long-term use of left ventricular assist systems. Severe pocket infection is especially difficult to manage and removal of the device has been the only curative treatment in most cases. We report a case of a Novacor device pocket infection treated successfully with continuous local irrigation and transposition of omental flap. This procedure provides another option for the management of pocket infection, which is mandatory for destination therapy the permanent usage of LVAS for the purpose of circulatory supports in patients with end–stage heart failure, who are not indicated for heart transplantation.
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Introduction
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The large discrepancy between the supply of donor hearts and the number of heart transplantation is causing longer waiting times and stimulating the long-term use of left ventricular assist system (LVAS) including destination therapy [1]. One of the major obstacles to the long-term use of LVAS support is device-related infection, which includes infection in drive-line exit site or pump pocket and device-valve endocarditis [1–5]. Among those complications, severe pump pocket infection is a devastating problem requiring device removal or exchange unless cardiac transplantation is performed within a short time [2–4]. We report the successful treatment of purulent infection in the device pocket by a staged application of drainage, continuous local irrigation, and transposition of a pedicled omental flap.
In a 33-year-old man with a long history of idiopathic dilated cardiomyopathy cardiogenic shock developed despite intense medical treatment. We implanted a Novacor N100 (Baxter Healthcare, Oakland, CA) LVAS in the posterior sheath of the rectal muscle as previously described. Vancomycin and ceftazidime were administered for 1 week postoperatively. Although his initial postoperative course was uneventful a large hematoma developed in the device pocket on the third postoperative week. Through the previous abdominal incision he underwent drainage of clot, which grew no significant organisms. Three months after LVAS implantation purulent discharge began to drain from the drive-line exit site and grew Staphylococcus aureus and Serratia malcessence. A 2-week course of antibiotics treatment with vancomycin and imipenum improved the infectious signs. One month later, however, the patient had a high fever and tension and tenderness developed over the device pocket. Exploration with a tap needle demonstrated purulent fluid in the device pocket.
The patient was taken to an operating room and a large amount of pus was drained through several small incisions on the abdominal wall over the pump pocket. Two tubes for infusion and one for drainage were placed through the incisions into the pocket and the pocket was continuously irrigated with 0.5% polyvinylpyrrolidone-iodine solution for 1 week and with saline for another week. The infectious signs of fever, chill, and elevation of white blood cell count were controlled with those treatments. The pus from the pocket grew S aureus. On postdrainage day 14 we reopened the LVAS pocket from the lower midline incision. Some residual pus was found in the pocket. After the vigorous irrigation of the pocket, the posterior sheath of the rectal muscle and the peritoneum was opened behind the device. As the outflow graft just lies at the midline, only a 15-cm opening of the abdominal cavity was obtained. By pulling out the stomach and transverse colon sequentially, a pedicled omental flap of approximately 50 cm of each side was created. The device was wrapped with the omental flap (Fig 1)
and the wound was closed. The patient received an 8-week course of intravenous vancomycin therapy that was switched to oral antibiotics therapy thereafter. As the drive-line exit site continues to drain another organism, he is still receiving antibiotics. The infection in the pomp pocket has not recurred however, and he is doing well and awaiting heart transplantation 1 year after the device implantation and 9 months after the omental transposition.
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Comment
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Pump pocket infection as seen in our case may be secondary to blood stream infection as well as primary wound contamination. Tjan and associates [3] described 3 patients who had necrosis of the abdominal or thoracic wall uncovering part of the device. Their cases required, as did our case, multiple surgical revisions after the LVAS implantation for bleeding complications. The local hematoma in the pocket may also be important as a focus of infection. Careful use of sterile techniques and meticulous hemostasis during the operation may be the best prophylaxis for the pocket infection. Intraperitoneal insertion of the device is regaining attention because it is associated with a lower incidence of infectious complications but it may result in serious gut complications such as intestinal perforation.
There has been no effective treatment for severe device pocket infection except to follow the general rule of treating infected prosthetic materials, ie, removing the device and performing the cardiac transplantation [2–4]. To realize the permanent use of LVAS, however, an effective treatment for this problem is mandatory. We utilized a pedicled flap of greater omentum, which is widely used to manage infection of prosthetic materials including vascular grafts in thoracic surgery [6]. Its usefulness for controlling infection supposedly depends on the increased blood supply to infected areas, thus intensifying inflammatory cell infiltration and increasing tissue concentration of antibiotics. The pedicled flap also absorbs necrotic tissue and fluid and fills dead space, thus reducing the possibility of regrowth of residual bacteria. Although there were some difficulties in making the omental flap through the limited incision behind the LVAS pump, the careful surgical procedure made it possible to create a flap wide enough to fill the device circumferentially.
In summary surgical drainage, local irrigation, and omental transposition into the device pocket are effective treatment options to control the pocket infection. This case implies a prophylactic use of the omental flap in the pump pocket located in the abdominal wall during the implant operation when a long waiting time is expected or a device is implanted as a destination therapy.
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References
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- Rose E.A., Gelijns A.C., Moskowitz A.J., et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435-1443.[Abstract/Free Full Text]
- McCarthy P.M., Schmitt S.K., Vargo R.L., Gordon S., Keys T.F., Hobbs R.E. Implantable LVAD infection. Implication for permanent use of the device. Ann Thorac Surg 1996;61:359-365.[Abstract/Free Full Text]
- Tjan T.D.T., Asfour B., Hammel D., Schmidt C., Scheld H.H., Schmid C. Wound complications after left ventricular assist device implantation. Ann Thorac Surg 2000;70:538-541.[Abstract/Free Full Text]
- 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]
- Gordon S.M., Schmitt S.K., Jacobs M., et al. Nosocomial bloodstream infections in patients with implantable left ventricular assist devices. Ann Thorac Surg 2001;72:725-730.[Abstract/Free Full Text]
- Luciani N., Lapenna E., Bonis M.D., Possati G.F. Mediastinitis following graft replacement of the ascending aorta: conservative approach by omental transposition. Eur J Cardiothorac Surg 2001;20:418-420.[Abstract/Free Full Text]
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G. Matsumiya, Y. Miyamoto, N. Fukushima, O. Monta, Y. Sawa, and H. Matsuda
Intraabdominal placement of a Novacor ventricular assist system by using an expanded polytetrafluoroethylene pouch
Ann. Thorac. Surg.,
May 1, 2004;
77(5):
1851 - 1853.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
