Scientific Letter
Three-stage treatment of late mediastinitis after implantation of left ventricular assist device
Tratamiento en tres fases de mediastinitis retardada después de implantación de un dispositivo para asistencia del ventrículo izquierdo
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"apellidos" => "Román-Maestre" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572716300546?idApp=WMIE" "url" => "/21735727/0000004000000008/v1_201611050100/S2173572716300546/v1_201611050100/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Three-stage treatment of late mediastinitis after implantation of left ventricular assist device" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "514" "paginaFinal" => "516" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A.M. Scandroglio, E. Potapov, M. Pieri, G. Arlt, V. Falk, T. Krabatsch" "autores" => array:6 [ 0 => array:3 [ "nombre" => "A.M." "apellidos" => "Scandroglio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Potapov" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "M." "apellidos" => "Pieri" "email" => array:1 [ 0 => "pieri.marina@hsr.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Arlt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "V." "apellidos" => "Falk" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "T." "apellidos" => "Krabatsch" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department for Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento en tres fases de mediastinitis retardada después de implantación de un dispositivo para asistencia del ventrículo izquierdo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1943 "Ancho" => 2685 "Tamanyo" => 338072 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Outline of the three-stage treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Left ventricular assist device (LVAD) infection is a major cause of re-admission during long-term follow-up and is associated with very high morbidity and mortality. The VAD-related mediastinitis mortality rate is up to 70%.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1–3</span></a> We describe successful three-stage treatment: 1st stage, explantation of the infected device and implantation of peripheral extracorporeal life support (ECLS), followed by surgical toilet of the infected mediastinum employing jet lavage and vacuum drainage; 2nd stage, mobilization of the great omentum and wrapping around the heart including apex; and 3rd stage, implantation of a new LVAD outside of mediastinum and explantation of ECLS (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">A 42-year-old man (175<span class="elsevierStyleHsp" style=""></span>cm and 110<span class="elsevierStyleHsp" style=""></span>kg-BSA 2.24<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>) with ischemic cardiomyopathy, type 2 diabetes mellitus, arterial hypertension, chronic renal failure (stage III), and paroxysmal atrial fibrillation was supported with Heart Mate III LVAD (Thoratec Corp, Pleasanton, CA) at Deutsches Herzzentrum Berlin.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Six months after hospital discharge, the patient presented with a subxyphoidal abscess and signs of systemic infection (white blood cells 12.6<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, C reactive protein 24<span class="elsevierStyleHsp" style=""></span>mg/dl, procalcitonin 23.1 micrograms/L, and body temperature 38.9<span class="elsevierStyleHsp" style=""></span>°C). The exit site of the driveline was completely healed and free of infection. The thoracic CT scan revealed presternal collection of fluid with no evidence of intrathoracic involvement. Over 300<span class="elsevierStyleHsp" style=""></span>ml of purulence was evacuated during surgical drainage. The cable was involved in the abscess. Additionally, jet lavage was performed with 3 liters of warm 0.9% NaCl solution and a vacuum assisted closure (VAC) system was applied. Systemic antibiotics (fosfomycin and rifampicin) were administered to address methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> (MSSA) isolated from purulent drainage and blood samples obtained at hospital admission. The patient was extubated and orally fed. The dosage of the antimicrobic therapy was the maximal dose recommended according to the organ function throughout the whole clinical course.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient showed clinical improvement with reduction of infection markers and no fever, but, during 3rd VAC exchange, he presented continuous bleeding from the wound originating from the proximal part of the cable exiting. Loosening of the apical fixation ring connection was suspected. Ten days after hospital admission, re-sternotomy was performed. The apical cuff of the device was found to be partially detached from the apex causing bleeding. Macroscopic evidence of infection was found. Peripheral ECLS was implanted, including distal leg perfusion, and all the components of the LVAD were explanted. The apex of the heart was repaired with prolene sutures and a pericardial patch. In order to achieve full sterilization of the thorax, the sternum was left open and treated with repeated jet lavage and VAC. Systemic multidrug intravenous antibiotic therapy, including gentamicin, flucloxacillin, and linezolid, was administered for several weeks. Fourteen days after surgery limb ischemia occurred and required surgical treatment including thrombectomy and cannulation of the contralateral femoral artery. Already after few days after the first operation the wound samples were sterile in the absence of bacteremia, therefore, after 18 days of ECLS, omental flap plasty and sternal closure were performed.</p><p id="par0025" class="elsevierStylePara elsevierViewall">One week later and 27 days after removal of infected LVAD, with the patient breathing spontaneously on ECLS and without signs of systemic infection (white blood cells 7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, C reactive protein 16.6<span class="elsevierStyleHsp" style=""></span>mg/dl, procalcitonin 0.31 micrograms/L, and body temperature 37.3<span class="elsevierStyleHsp" style=""></span>°C) he underwent re-implantation of an LVAD (HVAD HeartWare International, Inc., Framingham, MA) from apex to descending aorta through left lateral thoracotomy, as described previously.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4,5</span></a> The new driveline course does not intersect with the previous one and has a new exit site; in the same session the ECLS was explanted.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The postoperative course was complicated by pump thrombosis on day 7 with subsequent pump exchange as described,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> and by groin infection treated with surgical revision and VAC therapy. The patient was stable, without signs of systemic infection and partially rehabilitated. Antibiotic therapy continued although blood cultures were negative, while intraoperative samples from the left groin identified <span class="elsevierStyleItalic">Candida glabrata</span> and <span class="elsevierStyleItalic">Klebsiella pneumonia</span>. According to the antibiogram, rifampicin and flucloxacillin were discontinued (total duration of therapy was 43 and 36 days, respectively), and caspofungin and ceftazidime were started. Unfortunately, after further 35 days of hospitalization the patient died due to sudden intracerebral bleeding.</p><p id="par0035" class="elsevierStylePara elsevierViewall">If the pump is infected, surgical cleaning of the mediastinum, debridement and vacuum treatment and, finally, transposition of the great omentum with wrapping around the pump have been successfully used in our institution and also described by other authors.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7–10</span></a> Retention of potentially infected inflow or outflow cuffs could contribute to infection recurrence, and apex involvement with loosening of the fixation ring is still an unsolved problem. Severe pump infection may be controlled by device explantation if the cardiac function has fully recovered,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">11,12</span></a> wrapping with the great omentum<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7–10</span></a> or by pump exchange.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> However, in a devastating case of apex infection with bleeding, switching the inflow cannula from apex to left atrium is an option. In our case temporary implantation of the Berlin Heart Excor (Berlin Hear AG, Berlin, Germany) or Levitronix Centrimag (Levitronix, Framingham, MA) from left atrium to ascending aorta<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> would bring foreign material into the infected mediastinum. Connection to the descending aorta may lead to infection of the left pleural space precluding the implantation of the long-term pump through a left lateral thoracotomy. Therefore we decided to use peripheral ECLS to avoid opening the pleural space or introducing any additional cannula in or close to the infected situs. The thorax was free from any MCS components and the choice to leave it open allowed application of all topical treatments in addition to iv antimicrobic drugs.</p><p id="par0040" class="elsevierStylePara elsevierViewall">For ECLS, cannulation of the subclavian artery and jugular vein to allow better mobilization of the patient would also have been an option.</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is important that the new pump does not come into contact with the previously infected tissue – in the present case the new pump was implanted, with new access to the thorax, 9 days after the omentum was wrapped around the sterile apex acting as a biological barrier to infection.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, pump infection with apex involvement is rare but can be disastrous. A staged surgical approach including complete removal of infected foreign material, sterilization of the wound by surgical debridement and VAC, closure of the wound with the highly immune competent great omentum and, finally, re-implantation of an LVAD outside the infected field may be effective.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interests and source of funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">No conflicts of interest. The work was supported by departmental funds</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interests and source of funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1943 "Ancho" => 2685 "Tamanyo" => 338072 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Outline of the three-stage treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Society for Heart and Lung Transplantation. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 11 | 21 |
| 2024 October | 37 | 51 | 88 |
| 2024 September | 52 | 42 | 94 |
| 2024 August | 50 | 50 | 100 |
| 2024 July | 35 | 37 | 72 |
| 2024 June | 41 | 42 | 83 |
| 2024 May | 40 | 39 | 79 |
| 2024 April | 48 | 37 | 85 |
| 2024 March | 33 | 22 | 55 |
| 2024 February | 29 | 40 | 69 |
| 2024 January | 21 | 38 | 59 |
| 2023 December | 32 | 35 | 67 |
| 2023 November | 27 | 32 | 59 |
| 2023 October | 29 | 24 | 53 |
| 2023 September | 29 | 34 | 63 |
| 2023 August | 19 | 18 | 37 |
| 2023 July | 29 | 20 | 49 |
| 2023 June | 26 | 16 | 42 |
| 2023 May | 42 | 39 | 81 |
| 2023 April | 52 | 23 | 75 |
| 2023 March | 67 | 30 | 97 |
| 2023 February | 52 | 23 | 75 |
| 2023 January | 32 | 32 | 64 |
| 2022 December | 43 | 36 | 79 |
| 2022 November | 48 | 24 | 72 |
| 2022 October | 39 | 29 | 68 |
| 2022 September | 20 | 29 | 49 |
| 2022 August | 30 | 33 | 63 |
| 2022 July | 17 | 23 | 40 |
| 2022 June | 32 | 25 | 57 |
| 2022 May | 68 | 33 | 101 |
| 2022 April | 27 | 25 | 52 |
| 2022 March | 41 | 42 | 83 |
| 2022 February | 24 | 22 | 46 |
| 2022 January | 22 | 39 | 61 |
| 2021 December | 46 | 36 | 82 |
| 2021 November | 38 | 35 | 73 |
| 2021 October | 51 | 67 | 118 |
| 2021 September | 23 | 33 | 56 |
| 2021 August | 38 | 32 | 70 |
| 2021 July | 36 | 36 | 72 |
| 2021 June | 25 | 17 | 42 |
| 2021 May | 46 | 48 | 94 |
| 2021 April | 68 | 58 | 126 |
| 2021 March | 57 | 24 | 81 |
| 2021 February | 61 | 30 | 91 |
| 2021 January | 35 | 16 | 51 |
| 2020 December | 34 | 17 | 51 |
| 2020 November | 23 | 27 | 50 |
| 2020 October | 32 | 31 | 63 |
| 2020 September | 36 | 12 | 48 |
| 2020 August | 79 | 17 | 96 |
| 2020 July | 56 | 14 | 70 |
| 2020 June | 33 | 19 | 52 |
| 2020 May | 31 | 9 | 40 |
| 2020 April | 21 | 12 | 33 |
| 2020 March | 9 | 9 | 18 |
| 2020 February | 63 | 56 | 119 |
| 2020 January | 19 | 23 | 42 |
| 2019 December | 25 | 24 | 49 |
| 2019 November | 24 | 21 | 45 |
| 2019 October | 17 | 19 | 36 |
| 2019 September | 21 | 24 | 45 |
| 2019 August | 30 | 9 | 39 |
| 2019 July | 24 | 20 | 44 |
| 2019 June | 23 | 17 | 40 |
| 2019 May | 39 | 25 | 64 |
| 2019 April | 19 | 13 | 32 |
| 2019 March | 9 | 20 | 29 |
| 2019 February | 21 | 24 | 45 |
| 2019 January | 23 | 34 | 57 |
| 2018 December | 30 | 22 | 52 |
| 2018 November | 33 | 48 | 81 |
| 2018 October | 48 | 27 | 75 |
| 2018 September | 16 | 6 | 22 |
| 2018 August | 11 | 6 | 17 |
| 2018 July | 18 | 5 | 23 |
| 2018 June | 22 | 6 | 28 |
| 2018 May | 20 | 5 | 25 |
| 2018 April | 8 | 4 | 12 |
| 2018 March | 11 | 3 | 14 |
| 2018 February | 16 | 6 | 22 |
| 2018 January | 19 | 6 | 25 |
| 2017 December | 14 | 3 | 17 |
| 2017 November | 19 | 8 | 27 |
| 2017 October | 14 | 6 | 20 |
| 2017 September | 11 | 4 | 15 |
| 2017 August | 11 | 6 | 17 |
| 2017 July | 15 | 12 | 27 |
| 2017 June | 15 | 6 | 21 |
| 2017 May | 18 | 11 | 29 |
| 2017 April | 19 | 14 | 33 |
| 2017 March | 8 | 0 | 8 |
| 2017 February | 7 | 0 | 7 |
| 2016 November | 1 | 0 | 1 |
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