Plastic & Reconstructive Surgery:
Exposed Left Ventricular Assist Device Salvage Using the Components Separation Technique
Buck, Donald W. II M.D.; McCarthy, Patrick M. M.D.; McGee, Edwin Jr M.D.; Kim, John Y. S. M.D.
Division of Plastic and Reconstructive Surgery (Buck)
Division of Cardiothoracic Surgery (McGee, McCarthy)
Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Ill. (Kim)
Correspondence to Dr. Kim, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 675 North St. Clair Street, Suite 19-250, Chicago, Ill. 60611, email@example.com
Heart failure is the leading cause of death in developed nations worldwide.1 Management of severe disease is limited, with cardiac transplantation and long-term mechanical assistance being the only definitive therapeutic options.1,2 In patients awaiting transplantation, left ventricular assist devices provide temporary support until a donor heart becomes available or myocardial function improves. Although ventricular assist devices have revolutionized the current algorithm for cardiac transplantation, their use is not without risks and complications. Left ventricular assist device infections occur in a reported 18 to 59 percent of cases.1 Left ventricular assist device infection can have catastrophic outcomes if not treated early and effectively.
The mainstay of treatment is antibiotic therapy, with local wound care and eventual pump removal.1 Because of poor perfusion in the pump pocket, formation of bacterial biofilms, and surrounding scarring, microbes involved in left ventricular assist device infections are somewhat protected from antibacterial medications, necessitating healthy vascularized tissue recruitment to promote healing and antibiotic penetrance.3
A 32-year-old man with a remote history of reticulum cell sarcoma, treated with an above-knee amputation and Adriamycin (Pharmacia & Upjohn, Bridgewater, N.J.), was admitted to the intensive care unit in cardiogenic shock. Three weeks after admission, a left ventricular assist device was implanted as a bridge to cardiac transplantation. Two months after left ventricular assist device implantation, the patient developed wound dehiscence and evidence of a pump pocket infection. After pump pocket debridement, the soft-tissue defect measured approximately 12 × 8 cm in size. The left ventricular assist device itself was entirely exposed (Fig. 1). An intraoperative decision was made to perform bilateral, bipedicled rectus myocutaneous flaps using the components separation technique.
Longitudinal incisions were made, bilaterally, along the lateral anterior abdominal lines, with dissection carried down to the external oblique/rectus muscle junction. The rectus muscle was then dissected off of the oblique laterally and freed up along the deep and superficial aspects as well. The superior and inferior portions of the muscle were not dissected, maintaining a bipedicled blood supply from both the superior and inferior epigastric vessels. The patient, a competitive body builder, had a very muscular abdominal wall, and the lateral relaxing incisions allowed complete mobilization of the rectus muscle flaps, resulting in sufficient midline advancement to cover the exposed left ventricular assist device (Fig. 2). A vacuum-assisted closure device was applied to the lateral defects. These defects were definitively closed with split-thickness skin grafts after substantial contraction had occurred. Six months after left ventricular assist device salvage, the patient successfully underwent orthotopic cardiac transplantation. Intraoperative cultures at the time of this procedure were negative for persistent infection.
The components separation technique should be considered a viable option for treatment of left ventricular assist device infection. Prior reports detail the use of omental and unilateral rectus myocutaneous flaps for left ventricular assist device salvage.4,5 In contrast to these flaps, the components separation technique provides a bipedicled flap to ensure the presence of rich vascular tissue within the pocket, further enhancing antibiotic access. In addition, this technique provides adequate and symmetrical tissue bulk to obliterate dead space and obviate the need for abdominal exploration and omental harvest.
Donald W. Buck, II, M.D.
Division of Plastic and Reconstructive Surgery
Edwin McGee, Jr., M.D.
Patrick M. McCarthy, M.D.
Division of Cardiothoracic Surgery
John Y. S. Kim, M.D.
Division of Plastic and Reconstructive Surgery
Feinberg School of Medicine
The authors have no conflict of interest regarding this research.
1. Gordon, R. J., Quagliarello, B., and Lowy, F. D. Ventricular assist device-related infections. Lancet Infect. Dis. 6: 426, 2006.
2. Rose, E. A., Gelijns, A. C., Moskowitz, A. J., et al. Long-term mechanical left ventricular assistance for end-stage heart failure. N. Engl. J. Med. 345: 1435, 2001.
3. Heerdt, P. M., Holmes, J. W., Cai, B., et al. Chronic unloading by left ventricular assist device reverses contractile dysfunction and alters gene expression in end-stage heart failure. Circulation 102: 2713, 2000.
4. Hutchinson, O. Z., Oz, M. C., and Ascherman, J. A. The use of muscle flaps to treat left ventricular assist device infections. Plast. Reconstr. Surg. 107: 364, 2001.
5. Sajjadian, A., Valeria, I. L., Acurturk, O., et al. Omental transposition flap for salvage of ventricular assist devices. Plast. Reconstr. Surg. 118: 919, 2006.
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