Ann Thorac Surg 2004;78:1820-1821
© 2004 The Society of Thoracic Surgeons
Case report
Heart Transplantation in a Patient With a Left Ventricular Assist Device and Methicillin-Resistant Staphylococcus Aureus Infection
Christof Schmid, MD*,a,
Michael Schneider, MDa,
Christian Etz, MDa,
Hans H. Scheld, MDa
a Department of Thoracic and Cardiovascular Surgery, University Hospital, Muenster, Germany
Accepted for publication July 17, 2003.
* Address reprint requests to Dr Schmid, Department of Thoracic and Cardiovascular Surgery, University Hospital, Albert-Schweitzer-Str 33, Muenster 48149, Germany
schmid{at}uni-muenster.de
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Abstract
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We report a patient who underwent implantation of a DeBakey left-ventricular assist device and developed a methicillin-resistant Staphylococcus aureus drive line infection on postoperative day 304. The patient was forwarded to urgent heart transplantation with a successful outcome.
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Introduction
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Bacterial infection is a frequent complication after implantation of a left ventricular assist device [1]. In the early days, device contamination was associated with a rather unfavorable outcome, but results have considerably improved over the years. Ultimately, device infection became an indication rather than a contraindication for heart transplantation, as has also been the experience in our center [2]. However, along with the remarkable achievements in intensive care medicine, methicillin-resistant staphylococcus aureus (MRSA) infection became a tremendous hygienic problem in cardiosurgical units. Usually phenotypic and genotypic analyses are applied for epidemiologic differentiation, but its results do not interfere with therapeutic strategies. The affected patients have to be strictly isolated, because transmission is mainly due to dermal contact, and therapeutic measures are rather limited.
We report a patient with a left ventricular assist device who was forwarded to urgent heart transplantation because of MRSA infection. This 17-year-old boy suffering from dilative cardiomyopathy underwent implantation of a DeBakey left ventricular assist device in September 2001 after successful resuscitation from cardiogenic shock. After an uneventful postoperative course, he was discharged home and treated on an ambulatory basis. Regular surveillance swab specimens of the drive line exit revealed drive line infection with MRSA on day 304 after left ventricular assist device implantation. A nasal swab was negative. The patient was asymptomatic; there was neither inflammation nor secretion at the drive line exit. We decided to treat him with mupirocin nasal ointment, but MRSA positive cultures persisted. Because the patient did not develop signs of infection or sepsis, we left him on the waiting list for heart transplantation. After 426 days of mechanical support, a suitable donor organ became available, and heart transplantation was performed employing standard techniques. The patient was kept isolated after the procedure. The patient was able to be extubated on postoperative day 1 and was referred to the general ward on day 4. Treatment with the mupirocin ointment, which has to be administered intranasally, continued as did Betadine brushing of the former drive line exit. Fifteen days after transplantation, isolation was ended as repetitive swabs remained negative (ie, eradication of the MRSA was assumed). During the whole postoperative period, the routine immunosuppressive protocol was not altered. We did not use induction therapy, but we did use a triple-drug treatment consisting of cyclosporine A, azathioprine, and methylprednisolone.
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Comment
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A lot of experience with MRSA has been gained in liver transplant recipients, in which nasal carriage and consecutive MRSA infection has been reported to occur in more than 20% of patients. In a recent report, 30-day mortality was 21%, and 86% of patients with pneumonia or abdominal infection died [3]. Information on heart transplant patients with MRSA is sparse. Hsu and colleagues [4] reported on a perfusionist-transmitted mediastinitis in a heart transplant recipient in 2001, and Madden and colleagues [5] reported on a pyogenic psoas abscess in 2002. We were confronted with the rather unique situation of an MRSA infection in a patient with an axial flow pump that was implanted with a bridge-to-transplant intention. Being aware that Staphylococcus aureus infection is a substantial cause of mortality and morbidity in hospitalized patients (especially in cases of immunosuppressed states and presumably also in patients with ventricular assisted devices), we aimed at removing the device, because otherwise the MRSA eradication was deemed impossible. As the patient's heart had not recovered to allow weaning from the long-term mechanical support, the question was whether we should go forward with the heart transplantation or consider device infection with MRSA a contraindication for it. Taking into account our own experience with patients on ventricular assisted devices, and considering that our patient was asymptomatic, we voted for heart transplantation. We applied for high urgency priority at Eurotransplant, which was accepted, and we performed immediate transplantation. No special measures were taken during surgery, except a temporary isolation of the patient. Systemic antibiotic treatment was routine, but mupirocin nasal ointment was added. Transplantation was uniformly successful; the patient recovered well and did not suffer an infectious complication. One may ask whether we would have acted the same way in case of clinically evident infection (ie, purulent infection). The answer is definitely yes, because we know as well as others that in cases of purulent infection, complete removal of the contaminated device is even more important, and chances for successful transplantation are fairly good [6].
We conclude, that patients with ventricular assist devices who have MRSA infection can be transplanted like all other patients with ventricular assist devices and bacterial infections.
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References
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- Tjan TDT, Asfour B, Hammel D, Schmidt C, Scheld HH, Schmid C. Severe wound complications after left ventricular assist device. 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]
- Singh N, Paterson DL, Chang FY, et al. Methicillin-resistant staphylococcus aureus: the other emerging resistant gram-positive coccus among liver transplant recipients. Clin Infect Dis. 2000;30:322–327[Medline]
- Hsu RB, Chen ML, Chang SC, et al. Perfusionist-transmitted bacterial mediastinitis in a heart transplant recipient. Tex Heart Inst J. 2001;28:60–62[Medline]
- Madden BP, Datta S, Planche T. Pyogenic psoas abscess: a rare complication after orthotopic heart transplantation. J Heart Lung Transpl. 2002;21:928–931[Medline]
- 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]
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Abstract
Introduction
