Flap Reconstruction For Infectious Complications After Ventricular Assist Device Implantation
David Chi, MD PhD1, Danielle J. Brown, MD1, Austin Y. Ha, MD1, Linh Vuong, BS2, Sarah N. Chiang, BS2, Ryan Sachar, AB2, Reme Arhewoh, BA2, Rajiv P. Parikh, MD, MHS1, Ida K. Fox, MD1.
1Washington University Division of Plastic and Reconstructive Surgery, Saint Louis, MO, USA, 2Washington University School of Medicine, Saint Louis, MO, USA.
Purpose: Advances in ventricular assist device (VAD) technology have increased the duration of device use in heart failure patients, both as bridge to cardiac transplant and destination therapy. However, the high infection rate associated with long-term prosthesis use presents a difficult challenge to the reconstructive surgeon given the concomitant patient comorbidities and impracticality of device removal. This study reports outcomes after flap reconstruction of VAD infections and factors predictive for morbidity and mortality.
Methods: A retrospective review of patients who underwent flap reconstruction of VAD infections between 2008-2018 was performed. The primary outcome variable was infection recurrence. Secondary outcome variables included re-operation, post-operative complication, and mortality. Baseline demographics and comorbidities, wound characteristics, and reconstructive strategy were also collected.
Results: Twenty-five patients, including 15 men and 10 women, who underwent flap reconstruction for VAD infections were identified. Omental flap reconstruction was performed in 4 (16%) patients, combination pectoralis and abdominis rectus flap reconstruction in 6 (24%) patients, rectus abdominis flap reconstruction in 11 (44%) patients, and pectoralis flap reconstruction in 4 (16%) patients. Wound cultures were positive in 19 (76%) patients with methicillin-resistant Staph aureus, Pseudomonas, and Corynebacterium species the most common. The overall complication rate was 56%: 6 (24%) patients required re-admission for recurrence of sternal wound infection within 90 days post-operatively and 5 (20%) patients were re-admitted for wound dehiscence. Of the 10 (40%) patients requiring all-cause re-operation within 90 days post-operatively, 5 (25%) required re-operation for recurrent infection. Patient mortality at one year was 32%. Type of flap reconstruction was not associated with re-infection (p = 0.65), re-operation (p = 0.46), or mortality (p = 0.96). Pre-operative renal insufficiency was a predictor of 1-year mortality (p < 0.05).
Conclusions: This retrospective analysis of flap reconstruction for VAD infections demonstrates a high rate of re-admission, re-operation, and mortality following surgical reconstruction. The rectus abdominis flap was the most common flap used, and the type of flap reconstruction was not predictive of adverse outcomes. Renal insufficiency was a predictor for patient mortality. Reconstructive should approach these patients with greater awareness of these factors, and further investigation is necessary to improve the treatment of this challenging surgical problem.
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