J Artif Organs DOI 10.1007/s10047-015-0881-6
CASE REPORT
Artificial Heart (Clinical)
Successful left ventricular assist device re-implantation with omental covering for MDRP device infection Hitoshi Inafuku1 • Yukio Kuniyoshi1 • Satoshi Yamashiro1 • Yuichi Totsuka1 Minoru Ono2
•
Received: 28 July 2015 / Accepted: 18 December 2015 Ó The Japanese Society for Artificial Organs 2016
Abstract We present a case of paracorporeal left ventricular assist device (p-LVAD)-related infection, caused by multi-drug resistant Pseudomonas aeruginosae (MDRP), and successfully treated by p-LVAD re-implantation with omental covering. A 59-year-old man underwent p-LVAD implantation and coronary artery bypass grafting after percutaneous cardiopulmonary support and intra-aortic balloon pumping for cardiogenic shock due to acute myocardial infarction. Then, he was registered for heart transplantation. He suffered from blood stream infection causative organism of Pseudomonas aeruginosa, 2 months after that operation. He underwent re-median sternotomy and open drainage, 15 months after the p-LVAD implantation. However, he suffered from septic shock due to MDRP. He underwent p-LVAD re-implantation under hypothermic circulatory arrest and iodine gauze packing, followed by omental covering of the all artificial materials in his body 10 days after that operation. Soon after that, the infection was well controlled and the intravenous antibiotics could be discontinued 2 months after that operation. He successfully underwent heart transplantation, 17 months after that procedure. We concluded that p-LVAD re-implantation with omental covering is seemed to be useful in the treatment of massive device infection. This procedure might be a novel
& Hitoshi Inafuku [email protected] 1
Department of Thoracic and Cardiovascular Surgery, University of the Ryukyus, 207, Nishihara 903-0215, Okinawa, Japan
2
Department of Cardiac Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyou-ku 113-8655, Tokyo, Japan
treatment for severe VAD-related infection until heart transplantation. Keywords Paracorporeal left ventricular assist device Bridge to transplantation Multi-drug resistant Pseudomonas aeruginosae Omentum
Introduction Left ventricular assist devices (LVADs) are effective as bridge-to-heart transplantation (BTT) therapy for end-stage heart failure [1, 2]. Nipro-Toyobo-paracorporeal pulsatileflow VAD (Nipro-VAD; Nipro, Osaka, Japan) has been used most commonly as a paracorporeal VAD (p-VAD) in Japan. In this p-VAD, outer blood pump must be connected to the heart and large vessels via thick inflow and outflow cannulae, which is associated with the risk of infection at the exit site [3]. Associated infection is the most common complication of VAD and it often results in significant morbidity and mortality among patients waiting for a heart transplant. Established infection is difficult to control because artificial materials cannot be removed until transplantation. Long-term antibiotics are also required to treat LVAD-related infections that include the exit site, the apical cuff, and artificial grafts, but these can cause bacteria to become multi-drug resistant (MDR). Some studies have shown that LVAD-related infection does not prevent successful transplantation [4, 5]. Thus, controlling LVADrelated infection using antibiotics, local drainage at the infection site, and VAD replacement is a critically important issue for patients on the transplant list. However, the morbidity and mortality rates of patients with infections of LVAD remain substantial [6]. Infections of LVAD caused by multi-drug resistant Pseudomonas aeruginosa (MDRP)
123
J Artif Organs
have never been cured. Here, we describe device infection caused by MDRP that was successfully treated by bridgeto-bridge LVAD re-implantation with omental covering.
Case report A-59-year-old man with cardiogenic shock due to acute myocardial infarction had been treated with a coronary artery bypass graft after percutaneous cardiopulmonary support and intra-aortic balloon pumping and then implanted with a Nipro-VAD. However, his heart function did not improve sufficiently to be considered for an LVAD explant and he was placed on the heart transplant list. The postoperative course was relatively uneventful. However, methicillin-resistant Staphylococcus aureus (MRSA) infected the wound and a brain hemorrhage occurred 2 months later. Gallium scintigram image revealed positive accumulation at the mediastinum, around the LV apex (apical cuff site) and around the xiphoid. Local debridement of the lower chest with drainage failed. A redo median sternotomy and drainage from the mediastinum and the LV apex proceeded at 13 months after the first operation. Then, the negative pressure wound therapy (NPWT) was applied to the mediastinum. However, the causative organism of the uncontrollable LVAD-related bloodstream infection had changed to Pseudomonas aeruginosa. One month later, septic shock occurred and cultures of blood and effusions from the apical cuff of the LVAD were positive for MDRP. Intravenous colistin and adjunct direct hemoperfusion using a polymyxin B-immobilized column (PMX-DHP) recovered hemodynamics, but could not eradicate the MDRP. We, therefore, re-implanted a Nipro-VAD with omental covering at 15 months after the first operation.
Fig. 1 Operative findings showed that healthy granulation was found around the heart and ascending aorta after negative pressure wound therapy. AA Ascending aorta, *outflow graft, **inflow cannula
Operative procedures A CPB was established via right femoral and right axillary arterial cannulation with right femoral venous drainage. Because the ascending aorta was covered with healthy granulation tissue (Fig. 1) after NPWT, we could not dissect the ascending aorta and also side biting clamp could not be used. After deep hypothermic circulatory arrest, we removed the inflow graft and debrided the ascending aorta at attachment site and found vegetation in the graft. After complete debridement of the ascending aorta at attachment site of this inflow graft, the defect was reached 20 mm (Fig. 2). Because there was significant size discrepancy between the defect of the ascending aorta and a new outflow graft (12 mm), a new 20 mm artificial graft was anastomosed to the ascending aorta and clamped. Then, the
123
Fig. 2 About 20 mm defect (upper triangle) was found at the ascending aorta after debridement of the anastomosis site of the outflow graft. A 20 mm artificial graft (**) was anastomosed to the ascending aorta. *Foley catheter, **20 mm artificial graft, upper triangle defect of the ascending aorta
J Artif Organs
CPB was restarted and we removed the apical cuff of the LV apex, completely debrided the LV apex, and applied a new apical cuff. Finally, a new outflow graft (12 mm) was then anastomosed to the 20 mm artificial graft. Thereafter, the patient was placed in the ICU with the chest left open. The vegetation from the excised artificial graft and apical cuff was positive for Pseudomonas aeruginosa. Repeated mediastinal lavage could not remove bacterial staining from the mediastinum. We finally covered all artificial materials with omentum 10 days after this operation. After a median laparotomy, the omentum was prepared with the gastroepiploic artery, transferred to the mediastinum, and all artificial materials including the graft, apical cuff, inflow cannula and outflow cannula were completely covered and the chest was closed. Cultures of mediastinal lavage and blood stained negative for bacterial infection after these procedures. Intravenous antibiotics were stopped 2 months later and he successfully underwent heart transplantation 17 months after that procedure.
outcomes are acceptable [12]. However, colistin could not eliminate the MDRP infection in our patient and we thus arranged bridge-to-bridge p-VAD re-implantation. We found that omental wrapping can effectively treat infectious aortic aneurysms [13, 14] and applied this technique for the LVAD-related infection in the patient described herein. In this setting, we preserved as many branches of the gastroepiploic artery as possible to completely cover all artificial materials. Our strategy should be used for the uncontrolled patients with severe VAD-related infection after long-term therapy of antibiotics, local drainage and NPWT. We concluded that VAD re-implantation with omental covering should be a useful strategy for treating severe VAD-related infection until heart transplantation. Acknowledgments This report was presented at a meeting of 5th congress of International Federation for Artificial Organs (IFAO2013), September27, 2013, Yokohama, Japan. Compliance with ethical standards
Discussion The Nipro-VAD is the only used device approved in Japan for bridge-to-candidacy (BTC) patients [7]. Although longterm management using the Nipro-VAD has remarkably improved, concerns about infection, cerebral hemorrhage, and the need for hospitalization until transplantation have remained unresolved [8]. Implantable, continuous-flow VADs (i-VAD) were approved for health insurance coverage to the patients registered for heart transplantation in April 2011 and they became important as bridges to transplantation. The outcomes of such treatment were better than those with p-VADs and the quality of life for the patients was improved because they could stay at home [9]. However, it was reported that p-VADs were still used in about one-fourth of all patients need for VADs. In Japan, p-VADs are used first to the patients who cannot be registered for transplantation and then replaced by i-VADs after transplant registry is done [3]. Conversion from the p-VAD to i-VAD is safe and practical for patients without infections [10]. However, our patient was not a candidate for conversion because of active infection and he had to await transplantation with a p-VAD. The wait for a heart transplant in Japan is the longest in the world, and about 95 % of registered heart transplant candidates require an LVAD during an average waiting period of 2.5 years [11]. The mortality and morbidity rates of patients with longterm circulatory assistance by a VAD that become infected with antibiotic-resistant organisms while in hospital are high [4]. Infection of an LVAD caused by MDRP has never been eradicated. Colistin (colistimethate sodium) is a safe option for treating MDRP infections, and the clinical
Conflict of interest
There is no conflict of interest.
References 1. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435–43. 2. Frazier OH, Rose EA, Oz MC, et al. Multicenter clinical evaluation of the HeartMate vented electric left ventricular assist system in patients awaiting heart transplantation. J Thorac Cardiovasc Surg. 2001;122:1186–95. 3. Nishimura T. Current status of extracorporeal ventricular assist devices in Japan. J Artif Organs. 2014;17:211–9. 4. Simon D, Fischer S, Grossman A, et al. Left ventricular assist device-related infection: treatment and outcome. Clin Infect Dis. 2005;40:1108–15. 5. Schulman AR, Martens TP, Russo MJ, et al. Effect of left ventricular assist device infection on posttransplant outcoms. J Heart Lung Transplant. 2009;28:237–42. 6. Holman WL, Skinner JL, Waites KB, Benza RL, McGiffin DC, Kirklin JK. Infection during circulatory support with ventricular assist devices. Ann Thorac Surg. 1999;68:711–6. 7. Suwa H, Seguchi O, Fujita T, et al. Paracorporeal ventricular assist device as a bridge to transplant candidacy in the era of implantable continuous-flow ventricular assist device. J Artif Organs. 2014;17:16–22. 8. Sasaoka T, Kato TS, Komamura K, et al. Improved long-term performance of pulsatile extracorporeal left ventricular assist device. J Cardiol. 2010;56:220–8. 9. Kyo S, Minami T, Nishimura T, Gojo S, Ono M. New era for therapeutic strategy for heart failure: destination therapy by left ventricular assist device. J Cardiol. 2012;59:101–9. 10. Yoshioka D, Sakaguchi T, Saito S, et al. Initial experience of conversion of Toyobo paracorporeal left ventricular assist device to DuraHeart left ventricular assist device. Circ J. 2012;76:372–6. 11. Kitamura S. Heart transplantation in Japan: a critical appraisal for the results and future prospects. Gen Thorac Cardiovasc Surg. 2012;60:639–44.
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J Artif Organs 12. Montero M, Horcajada JP, Sorli L, et al. Effectiveness and safety of colistin for the treatment of multidrug-resistant Pseudomonas aeruginosa infections. Infection. 2009;37:461–5. 13. Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms. Eur J Cardio Thorac Surg. 2013;43:1177–82.
123
14. Inafuku H, Senaha S, Morishima Y, et al. Infected thoracoabdominal aortic aneurysms including the major abdominal branches in 4 cases. Ann Thorac Cardiovasc Surg. 2008;14:196–9.
CASE REPORT
Artificial Heart (Clinical)
Successful left ventricular assist device re-implantation with omental covering for MDRP device infection Hitoshi Inafuku1 • Yukio Kuniyoshi1 • Satoshi Yamashiro1 • Yuichi Totsuka1 Minoru Ono2
•
Received: 28 July 2015 / Accepted: 18 December 2015 Ó The Japanese Society for Artificial Organs 2016
Abstract We present a case of paracorporeal left ventricular assist device (p-LVAD)-related infection, caused by multi-drug resistant Pseudomonas aeruginosae (MDRP), and successfully treated by p-LVAD re-implantation with omental covering. A 59-year-old man underwent p-LVAD implantation and coronary artery bypass grafting after percutaneous cardiopulmonary support and intra-aortic balloon pumping for cardiogenic shock due to acute myocardial infarction. Then, he was registered for heart transplantation. He suffered from blood stream infection causative organism of Pseudomonas aeruginosa, 2 months after that operation. He underwent re-median sternotomy and open drainage, 15 months after the p-LVAD implantation. However, he suffered from septic shock due to MDRP. He underwent p-LVAD re-implantation under hypothermic circulatory arrest and iodine gauze packing, followed by omental covering of the all artificial materials in his body 10 days after that operation. Soon after that, the infection was well controlled and the intravenous antibiotics could be discontinued 2 months after that operation. He successfully underwent heart transplantation, 17 months after that procedure. We concluded that p-LVAD re-implantation with omental covering is seemed to be useful in the treatment of massive device infection. This procedure might be a novel
& Hitoshi Inafuku [email protected] 1
Department of Thoracic and Cardiovascular Surgery, University of the Ryukyus, 207, Nishihara 903-0215, Okinawa, Japan
2
Department of Cardiac Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyou-ku 113-8655, Tokyo, Japan
treatment for severe VAD-related infection until heart transplantation. Keywords Paracorporeal left ventricular assist device Bridge to transplantation Multi-drug resistant Pseudomonas aeruginosae Omentum
Introduction Left ventricular assist devices (LVADs) are effective as bridge-to-heart transplantation (BTT) therapy for end-stage heart failure [1, 2]. Nipro-Toyobo-paracorporeal pulsatileflow VAD (Nipro-VAD; Nipro, Osaka, Japan) has been used most commonly as a paracorporeal VAD (p-VAD) in Japan. In this p-VAD, outer blood pump must be connected to the heart and large vessels via thick inflow and outflow cannulae, which is associated with the risk of infection at the exit site [3]. Associated infection is the most common complication of VAD and it often results in significant morbidity and mortality among patients waiting for a heart transplant. Established infection is difficult to control because artificial materials cannot be removed until transplantation. Long-term antibiotics are also required to treat LVAD-related infections that include the exit site, the apical cuff, and artificial grafts, but these can cause bacteria to become multi-drug resistant (MDR). Some studies have shown that LVAD-related infection does not prevent successful transplantation [4, 5]. Thus, controlling LVADrelated infection using antibiotics, local drainage at the infection site, and VAD replacement is a critically important issue for patients on the transplant list. However, the morbidity and mortality rates of patients with infections of LVAD remain substantial [6]. Infections of LVAD caused by multi-drug resistant Pseudomonas aeruginosa (MDRP)
123
J Artif Organs
have never been cured. Here, we describe device infection caused by MDRP that was successfully treated by bridgeto-bridge LVAD re-implantation with omental covering.
Case report A-59-year-old man with cardiogenic shock due to acute myocardial infarction had been treated with a coronary artery bypass graft after percutaneous cardiopulmonary support and intra-aortic balloon pumping and then implanted with a Nipro-VAD. However, his heart function did not improve sufficiently to be considered for an LVAD explant and he was placed on the heart transplant list. The postoperative course was relatively uneventful. However, methicillin-resistant Staphylococcus aureus (MRSA) infected the wound and a brain hemorrhage occurred 2 months later. Gallium scintigram image revealed positive accumulation at the mediastinum, around the LV apex (apical cuff site) and around the xiphoid. Local debridement of the lower chest with drainage failed. A redo median sternotomy and drainage from the mediastinum and the LV apex proceeded at 13 months after the first operation. Then, the negative pressure wound therapy (NPWT) was applied to the mediastinum. However, the causative organism of the uncontrollable LVAD-related bloodstream infection had changed to Pseudomonas aeruginosa. One month later, septic shock occurred and cultures of blood and effusions from the apical cuff of the LVAD were positive for MDRP. Intravenous colistin and adjunct direct hemoperfusion using a polymyxin B-immobilized column (PMX-DHP) recovered hemodynamics, but could not eradicate the MDRP. We, therefore, re-implanted a Nipro-VAD with omental covering at 15 months after the first operation.
Fig. 1 Operative findings showed that healthy granulation was found around the heart and ascending aorta after negative pressure wound therapy. AA Ascending aorta, *outflow graft, **inflow cannula
Operative procedures A CPB was established via right femoral and right axillary arterial cannulation with right femoral venous drainage. Because the ascending aorta was covered with healthy granulation tissue (Fig. 1) after NPWT, we could not dissect the ascending aorta and also side biting clamp could not be used. After deep hypothermic circulatory arrest, we removed the inflow graft and debrided the ascending aorta at attachment site and found vegetation in the graft. After complete debridement of the ascending aorta at attachment site of this inflow graft, the defect was reached 20 mm (Fig. 2). Because there was significant size discrepancy between the defect of the ascending aorta and a new outflow graft (12 mm), a new 20 mm artificial graft was anastomosed to the ascending aorta and clamped. Then, the
123
Fig. 2 About 20 mm defect (upper triangle) was found at the ascending aorta after debridement of the anastomosis site of the outflow graft. A 20 mm artificial graft (**) was anastomosed to the ascending aorta. *Foley catheter, **20 mm artificial graft, upper triangle defect of the ascending aorta
J Artif Organs
CPB was restarted and we removed the apical cuff of the LV apex, completely debrided the LV apex, and applied a new apical cuff. Finally, a new outflow graft (12 mm) was then anastomosed to the 20 mm artificial graft. Thereafter, the patient was placed in the ICU with the chest left open. The vegetation from the excised artificial graft and apical cuff was positive for Pseudomonas aeruginosa. Repeated mediastinal lavage could not remove bacterial staining from the mediastinum. We finally covered all artificial materials with omentum 10 days after this operation. After a median laparotomy, the omentum was prepared with the gastroepiploic artery, transferred to the mediastinum, and all artificial materials including the graft, apical cuff, inflow cannula and outflow cannula were completely covered and the chest was closed. Cultures of mediastinal lavage and blood stained negative for bacterial infection after these procedures. Intravenous antibiotics were stopped 2 months later and he successfully underwent heart transplantation 17 months after that procedure.
outcomes are acceptable [12]. However, colistin could not eliminate the MDRP infection in our patient and we thus arranged bridge-to-bridge p-VAD re-implantation. We found that omental wrapping can effectively treat infectious aortic aneurysms [13, 14] and applied this technique for the LVAD-related infection in the patient described herein. In this setting, we preserved as many branches of the gastroepiploic artery as possible to completely cover all artificial materials. Our strategy should be used for the uncontrolled patients with severe VAD-related infection after long-term therapy of antibiotics, local drainage and NPWT. We concluded that VAD re-implantation with omental covering should be a useful strategy for treating severe VAD-related infection until heart transplantation. Acknowledgments This report was presented at a meeting of 5th congress of International Federation for Artificial Organs (IFAO2013), September27, 2013, Yokohama, Japan. Compliance with ethical standards
Discussion The Nipro-VAD is the only used device approved in Japan for bridge-to-candidacy (BTC) patients [7]. Although longterm management using the Nipro-VAD has remarkably improved, concerns about infection, cerebral hemorrhage, and the need for hospitalization until transplantation have remained unresolved [8]. Implantable, continuous-flow VADs (i-VAD) were approved for health insurance coverage to the patients registered for heart transplantation in April 2011 and they became important as bridges to transplantation. The outcomes of such treatment were better than those with p-VADs and the quality of life for the patients was improved because they could stay at home [9]. However, it was reported that p-VADs were still used in about one-fourth of all patients need for VADs. In Japan, p-VADs are used first to the patients who cannot be registered for transplantation and then replaced by i-VADs after transplant registry is done [3]. Conversion from the p-VAD to i-VAD is safe and practical for patients without infections [10]. However, our patient was not a candidate for conversion because of active infection and he had to await transplantation with a p-VAD. The wait for a heart transplant in Japan is the longest in the world, and about 95 % of registered heart transplant candidates require an LVAD during an average waiting period of 2.5 years [11]. The mortality and morbidity rates of patients with longterm circulatory assistance by a VAD that become infected with antibiotic-resistant organisms while in hospital are high [4]. Infection of an LVAD caused by MDRP has never been eradicated. Colistin (colistimethate sodium) is a safe option for treating MDRP infections, and the clinical
Conflict of interest
There is no conflict of interest.
References 1. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435–43. 2. Frazier OH, Rose EA, Oz MC, et al. Multicenter clinical evaluation of the HeartMate vented electric left ventricular assist system in patients awaiting heart transplantation. J Thorac Cardiovasc Surg. 2001;122:1186–95. 3. Nishimura T. Current status of extracorporeal ventricular assist devices in Japan. J Artif Organs. 2014;17:211–9. 4. Simon D, Fischer S, Grossman A, et al. Left ventricular assist device-related infection: treatment and outcome. Clin Infect Dis. 2005;40:1108–15. 5. Schulman AR, Martens TP, Russo MJ, et al. Effect of left ventricular assist device infection on posttransplant outcoms. J Heart Lung Transplant. 2009;28:237–42. 6. Holman WL, Skinner JL, Waites KB, Benza RL, McGiffin DC, Kirklin JK. Infection during circulatory support with ventricular assist devices. Ann Thorac Surg. 1999;68:711–6. 7. Suwa H, Seguchi O, Fujita T, et al. Paracorporeal ventricular assist device as a bridge to transplant candidacy in the era of implantable continuous-flow ventricular assist device. J Artif Organs. 2014;17:16–22. 8. Sasaoka T, Kato TS, Komamura K, et al. Improved long-term performance of pulsatile extracorporeal left ventricular assist device. J Cardiol. 2010;56:220–8. 9. Kyo S, Minami T, Nishimura T, Gojo S, Ono M. New era for therapeutic strategy for heart failure: destination therapy by left ventricular assist device. J Cardiol. 2012;59:101–9. 10. Yoshioka D, Sakaguchi T, Saito S, et al. Initial experience of conversion of Toyobo paracorporeal left ventricular assist device to DuraHeart left ventricular assist device. Circ J. 2012;76:372–6. 11. Kitamura S. Heart transplantation in Japan: a critical appraisal for the results and future prospects. Gen Thorac Cardiovasc Surg. 2012;60:639–44.
123
J Artif Organs 12. Montero M, Horcajada JP, Sorli L, et al. Effectiveness and safety of colistin for the treatment of multidrug-resistant Pseudomonas aeruginosa infections. Infection. 2009;37:461–5. 13. Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms. Eur J Cardio Thorac Surg. 2013;43:1177–82.
123
14. Inafuku H, Senaha S, Morishima Y, et al. Infected thoracoabdominal aortic aneurysms including the major abdominal branches in 4 cases. Ann Thorac Cardiovasc Surg. 2008;14:196–9.
