Ann Thorac Surg 2003;76:610-611
© 2003 The Society of Thoracic Surgeons
Case report
Successful management of empyema in a patient with a total artificial heart
William F. Polito, MDa,
Francisco A. Arabia, MDa*,
Pei H. Tsau, MDa,
Venki Paramesh, MDb,
Daniel S. Woolley, MDa,
Raj K. Bose, MDa,
Gulshan K. Sethi, MDa,
Jack G. Copeland, MDa
a University of Arizona Sarver Heart Center, Tucson, Arizona,, USA
b Gunderson Lutheran Hospital, LaCross, Wisconsin, USA
Accepted for publication January 8, 2003.
* Address reprint requests to Dr Arabia, University of Arizona Sarver Heart Center, PO Box 245071, Tucson, AZ 85724-5071 USA
e-mail: arabia{at}u.arizona.edu
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Abstract
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A description of successful management of a patient who developed an empyema as a postoperative complication following the insertion of a CardioWest total artificial heart (TAH) as a bridge to cardiac transplantation is presented. By using traditional methods of management, the patient recovered and went on to transplant.
With the increasing number of patients needing cardiac transplantation for end-stage heart disease, and the number of donors remaining constant, the use of mechanical circulatory support has evolved as a new standard for bridge to transplant (BTT). The main complications of these devices include infection and thromboembolic events. We report a case of a patient who was treated for empyema while on the total artificial heart (TAH). He recovered, received an orthotopic heart transplant, and was discharged home without significant sequelae.
A 52 year-old male admitted with congestive heart failure (CHF) secondary to ischemic cardiomyopathy was referred for transplantation after failing medical management. He required the placement of an automatic implantable cardioverter device for malignant ventricular arrhythmias. An echo revealed a left ventricular ejection fraction (LVEF) 10% to 20%. He was stabilized, evaluated, and accepted for heart transplantation. During the next few months he had multiple admissions for CHF. Right heart catheterization revealed: CVP (central venous pressure) = 18 mm Hg; PCW (pulmonary capillary wedge pressure) = 29 mm Hg; CI = 1.9 L/min per m2; and systemic blood pressure = 82/52 (mean = 65 mm Hg), while on dopamine at 2.5 mcg/kg per min, dobutamine at 10 mcg/kg per min, and milrinone at 0.6 mcg/kg per min. Despite this aggressive support the patient continued to deteriorate and CardioWest TAH (CardioWest Technologies, Tucson, AZ) was implanted as BTT.
The operation was performed via a median sternotomy utilizing cardiopulmonary bypass. The pleural spaces were not entered during the implantation, and the device was protected with fashioned PTFE (polytetrafluoroethylene) membranes. Mechanical ventilation was discontinued on postoperative day 1 (POD 1). He was reintubated 2 days later for respiratory failure as a result of right lower lobe pneumonia. Initial sputum cultures identified the organism Klebsiella pneumoniae. Antibiotics were continued according to susceptibilities. Anticoagulation consisting of heparin initially then followed by warfarin, persantine, and aspirin was initiated. He was extubated 2 weeks following surgery, and was recovering slowly. Over the next 2 weeks he developed a right pleural effusion. A computed tomographic (CT) guided 12-French pigtail catheter was placed on POD 34 with evacuation of 1200 cc of serous fluid that revealed 2+ PMNs but no organisms. Pleural fluid recultured 5-days later revealed mixed anaerobic flora. Chest CT scan demonstrated a thickened fluid collection with a rind consistent with empyema (Fig 1).
On POD 43 he underwent a right thoracotomy with decortication; INR at this time was 2.4, with a bleeding time of 19.5 minutes. He developed a right hemothorax 4-days later requiring a second exploration and evacuation of the hemothorax. He recovered and was relisted as UNOS (United Network for Organ Sharing) status 1A for heart transplantation on POD 75. He underwent orthotopic heart transplantation on POD 159. He recovered without complications and was discharged home after 11 days.
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Fig 1. Computerized chest tomogram revealing a right-sided empyema and the CardioWest total artificial heart.
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The CardioWest TAH is currently used as a BTT and is under an investigation device exemption from the Food and Drug Administration.
It is a pneumatically driven device consisting of two polyurethane prosthetic ventricles that are placed in an orthotopic position via a median sternotomy. Blood and air are separated by a four-layer diaphragm that retracts in diastole and is displaced forward by compressed air during systole, propelling blood at flows of 6 to 8 L/min. Each ventricle has an inflow and outflow mechanical valves that direct blood between the respective atria and great vessels [1]. Once implanted, the ventricular drivelines exit the patient through the skin under the left costal margin and are connected to a driving console.
Empyema is a pleural space infection that can have a variety of etiologies. Most common are pneumonia, thoracic surgery, or trauma. Mortality ranges from 1% to 19% in most patients, however it can be as high a 40% in those that are immunocompromised [2]. The formation of an empyema occurs in three phases: exudative, fibrinopurulent, and organizing phase. The treatment is determined by the phase of the infection and the clinical status of the patient.
Infections following the placement of ventricular assist devices are well established as one of the most common complications [3]. A recent study of infections with the TAH reported 27 patients who had a total of 64 infections: 45 systemic and 19 local. Respiratory tract infection was the most common [4]. Mortality in this population was only 3.7%. Much is written concerning the infections and complications with these artificial devices, but only one offers management advice for noncardiac surgical issues [5]. In this patient, the large empyema posed a significant risk to his life and potentially the function of the TAH. Identifying an empyema early in its course allows for conservative measures such as tube thoracostomy or CT guided drainage, both of which were attempted in the patient. It is when these modalities are not successful that more invasive techniques must be used. With the patient having a TAH, a conservative plan was the original premise for our treatment. With the eventual organization of the empyema fluid and worsening clinical condition, a thoracotomy with decortication was necessary. Had it been sooner in the evolution of his empyema, VATS would have been a good option. A right anterior thoracotomy was performed in this patient with adequate drainage and decortication of the entrapped lung was performed. He did well intraoperatively and postoperatively, going on to transplantation without significant sequelae. This report demonstrates that despite having a mechanical circulatory support device, patients can and should be treated in a conventional manner for this potentially devastating infectious complication.
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References
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- Arabia F.A., Copeland J.G., Pavie A., Smith R.G. Implantation technique for the CardioWest total artificial heart. Ann Thorac Surg 1999;68:698-704.[Abstract/Free Full Text]
- Katariya K., Thurer R.J. Surgical management of empyema. Clin Chest Med 1998;19:395-406.[Medline]
- McCarthy P.M., Schmitt S.K., Vargo R.L., Gordon S., Keys T.F., Hobbs R.E. Implantable LVAD Infections: implications for permanent use of the device. Ann Thorac Surg 1996;61:359-365.[Abstract/Free Full Text]
- Copeland J.G., Smith R.G., Banchy M., et al. Infections with the CardioWest total artificial heart. ASAIO J 1998;44:M336-M339.[Medline]
- Goldstein D.J., Mullis S.L., Delphin E.S., et al. Noncardiac surgery in long-term implantable left ventricular assist-device recipients. Ann Surg 1995;222:203-207.[Medline]
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