Ann Thorac Surg 2005;80:1493-1495
© 2005 The Society of Thoracic Surgeons
Case report
Treatment of Ventricular Assist Device Driveline Infection With Vacuum-Assisted Closure System
David D. Yuh, MD
*
,
Maryann Albaugh, RN, BSN,
Susan Ullrich, RN, MSN,
John V. Conte, MD
Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland
Accepted for publication March 16, 2004.
* Address reprint requests to Dr Yuh, Division of Cardiac Surgery, Johns Hopkins Hospital, 600 North Wolfe St, Blalock 618, Baltimore, MD21287-4618 (Email: dyuh{at}csurg.jhmi.jhu.edu).
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Abstract
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Deep driveline infection is a serious complication after left ventricular assist device implantation. Current treatment strategies are associated with significant morbidity related to healing or relocation of the driveline tract. We present a case of deep driveline infection successfully treated with a vacuum-assisted closure system as a potentially improved alternative therapy.
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Introduction
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Current implantable left ventricular assist device (LVAD) designs and next-generation continuous-flow devices require a tunneled driveline to conduct energy, controller algorithms, and telemetric data between the pump and extracorporeal controller unit. Deep driveline tract infections constitute a common complication, often resulting in pocket or device infections, or both, refractory to medical treatment.
Several strategies for treating extensive LVAD driveline infections have been adopted over the years, yet all have significant disadvantages. Frequent dressing changes, long-term indwelling irrigation and drainage catheters, markedly shortened tracts, chronic infections, draining wounds, and suboptimal tract or exit site relocations have generally led to considerable morbidity. We describe the use of a vacuum-assisted wound closure system (KCI Inc, San Antonio, TX) as a potentially improved therapy for deep driveline infections.
An 18-year-old man with end-stage idiopathic dilated cardiomyopathy underwent uneventful placement of a HeartMate LVAD (Thoratec Corp, Pleasanton, CA) as a bridge to transplantation. He presented 3 months later with pain and erythema over the driveline site, particularly at the umbilicus. Although blood cultures were negative, exit site cultures revealed Pseudomonas and intravenous antibiotics were initiated. Computed tomography revealed a complex abscess deep within the driveline tract just inferior to the umbilicus (Fig 1). We opted to perform immediate surgical drainage of this abscess.
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Fig 1. Abdominal computed tomography revealing complex abscess fluid collection deep within the ventricular assist device driveline tract, below the umbilicus (anterior and midline). Note the enhancing driveline within the abscess collection.
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In the operating room, the tract was opened, drained, and debrided from the exit site back to the most proximal point where the subcutaneous tissues were circumferentially adherent to the velour driveline covering (Fig 2). The vacuum-assisted closure (VAC) system was then applied to the wound. An open-cell polyurethane ether foam material was fashioned and placed into the wound in direct contact with all subcutaneous tract surfaces. It was also wrapped circumferentially around the exposed driveline, which was left within this opened tract. An evacuation tube with side ports that communicate with the reticulated foam was embedded in the foam, permitting even distribution of the applied negative pressure to all spaces of the wound. The wound was then covered with an adhesive film, creating an airtight closed system. Finally, controlled suction was applied by connecting the evacuation tube to the vacuum pump, fitted with an in-line chamber to collect fluid and debris. This initial dressing was left in place for 48 hours.
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Fig 2. (A) Wide excision, drainage, and debridement of infected driveline tract. (B) Vacuum-assisted closure system applied to the opened driveline tract.
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The initial dressing change was performed sterilely, replacing the foam and adhesive film. The dressing was changed in this manner every 2 days thereafter until granulation tissue developed along the base of the tract, approximately 10 days later. The driveline was then permitted to lie in direct contact with this new tissue bed, with the VAC foam applied only along the anterolateral surfaces of the wound. Over several weeks, granulation tissue surrounded and became adherent to all aspects of the driveline, reestablishing the original tract and exit site (Fig 3). Once the tract became shallow, saline wet-to-dry or alginate dressing changes were applied. Intravenous antibiotics, initiated just before surgery, were continued throughout the 2-week admission and transitioned to oral antibiotics at discharge.
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Fig 3. Healing driveline tract approximately (A) 4 weeks and (B) 6 weeks after initial debridement. Note the exuberant granulation tissue with near circumferential adherence to the driveline. (B) The original tract and exit site are reestablished.
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A portable vacuum pump permitted the VAC therapy to be continued at home. The VAC suction tubing could be clamped and the pump could be disconnected for hours at a time, permitting mobility. Regular monitoring of the wound by our health care team, including wound care specialists, was conducted weekly to confirm adequate wound healing and to detect signs or symptoms of recurrent localized or systemic infection. The reestablished tract remains intact until the present time, 4 months after surgical debridement. The patient continues to do well while awaiting transplantation; his status was not upgraded during the treatment period.
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Comment
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Technical advances in LVAD technologies and the landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Trial catalyzed the long-term use of mechanical circulatory support systems in patients with end-stage congestive heart failure [1]. The anticipated increase in the extended implantation of current generation LVADs as "bridges" to cardiac transplantation or to recovery and "destination therapy" will likely accentuate assist device infections.
Driveline infections constitute a major complication of extended LVAD implantation [2–4]. Inadequate treatment can develop into life-threatening device infections, often requiring device exchange, long-term intravenous antibiotic therapy, or chronic indwelling pump pocket irrigation–drainage systems, or a combination thereof. These measures often entail extended hospitalizations or frequent outpatient visits until time of transplantation, recovery, or life-ending complication (eg, thromboembolism, sepsis, hemorrhage), effectively eliminating the intended outpatient autonomy afforded by these implantable devices.
Several management approaches have been used for the treatment of LVAD driveline infections; however each approach has significant drawbacks. Pasque and colleagues [5] advocated intravenous antibiotic therapy directed at the offending bacterial organisms, driveline immobilization, and complete circumferential exit site excision extending proximally (toward the pump) to the point where surrounding tissues are circumferentially adherent. This strategy is well-suited for localized exit site infections but has limited utility for more extensive, deeper driveline infections. Wide debridement leading to a shortened tract can result in an attenuated barrier to the pump pocket. Furthermore, displacement of the driveline to a more medial abdominal exit site after extensive tract debridement can present a significant hindrance to the patient's mobility. Other groups have advocated replacing the distal portion of the driveline in a new subcutaneous tunnel. This approach may place the deeper segments of the driveline at risk for infection. In addition, the patient's body habitus or pump orientation, or both, may limit options for alternative tract routes and exit sites.
We describe the use of a vacuum-assisted wound closure system to manage extensive driveline tract infections, which unlike other methods, this system reestablishes the original tract and exit site, accelerates healing, and simplifies wound management for the patient. The VAC system was first introduced by Morykwas and Argenta [6, 7] for the treatment of pressure ulcers and other chronic wounds. Based on the application of negative pressure by controlled suction to the wound surface, granulation tissue proliferation is promoted by arteriolar dilatation [8]. The continuous suction reduces excess fluid collection and tissue edema, reducing bacterial colonization. Finally, the VAC system effectively seals the wound from the environment, reducing gross contamination and mixed flora colonization. These characteristics appear to accelerate wound healing. With respect to cardiac surgery, the VAC system has been successfully applied to deep sternal wound infections incurred with median sternotomies, either as a bridge to reconstruction with a pectoralis muscle flap or in preparation for primary wound closure [8]. Our excellent experience with the VAC system in this context prompted our group to apply it to deep LVAD driveline tract infections.
We believe that our technique offers several advantages compared with other strategies in the management of extensive driveline tract infections. First, the VAC system permits definitive wide excision, drainage, and reestablishment of the original tract and exit site, obviating the need for re placement or repositioning of the driveline. Second, as with sternotomy wounds, the VAC system provides substantial wound stability, effectively immobilizing the driveline within the tract and optimizing conditions for circumferential tissue adherence to it. Third, the accelerated wound healing and closed-system configuration associated with the VAC approach would appear to be conducive to shorter hospital stays and outpatient wound care. Finally, by maintaining a hermetically sealed and well-drained environment over the redeveloping tract until circumferential tissue adherence around the driveline is reestablished, the tract and, by extension, the entire VAD system is protected from contamination. We plan on continuing this promising approach to validate its purported advantages.
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References
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- Rose EA, Moskowitz AJ, Packer M, et al. Long-term use of a left ventricular assist device for end-stage heart failure NEJM 2001;345:1435-1443.[Abstract/Free Full Text]
- Holman WL, Rayburn BK, McGiffin DC, et al. Infection in ventricular assist devicesprevention and treatment. Ann Thorac Surg 2003;75:S48-S57.[Abstract/Free Full Text]
- Fisher SA, Trenholme GM, Costanzo MR, et al. Infectious complications in left ventricular assist device recipients Clin Infect Dis 1997;24:18-23.[Medline]
- Grossi P, Dalla GD, Pagani F, et al. Infectious complications in patients with the Novacor left ventricular assist system Transplant Proc 2001;33:1969-1971.[Medline]
- Pasque MK, Hanselman T, Shelton K, et al. Surgical management of Novacor drive-line exit site infections Ann Thorac Surg 2002;74(4):1267-1268.[Abstract/Free Full Text]
- Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum assisted closure: a new method for wound control and treatment. Animal studies and basic foundation Ann Plast Surg 1997;38:553-562.[Medline]
- Argenta LC, Morykwas MJ. Vacuum assisted closure: a new method for wound control and treatment. Clinical experience Ann Plast Surg 1997;38:563-577.[Medline]
- Obdeijn MC, de Lange MY, Lichtendahl DHE, et al. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis Ann Thorac Surg 1999;68:2358-2360.[Abstract/Free Full Text]
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Abstract
Introduction
