Delayed Drive Line Site Soft Tissue Infection after Ventricular Assis Device Inactivation: A Case Report

摘要

IntroductionHeart transplantation is the treatment of choice for many patients with end-stage heart failure (HF). However, organ donor supply is limited. Ventricular assist devices (VAD) are increasingly used for the management of HF as a bridge to transplantation (BTT) or destination therapy (DT). Some patients with VADs have partial or full recovery of LV function thus qualifying for explant. Other patients may require an explant/exchange or pump inactivation due to complications of the device. While the infections at drive line site with active LVADs are seen in practice, we present a case of a delayed skin infection at the site of the original drive line. Case ReportA 45-year-old man with ischemic cardiomyopathy underwent HeartMate II implant in 2014 as BTT. His subsequent course was complicated by recurrent GI bleeding (GIB). He was admitted in 2016 with GIB and declined further use of Coumadin. He was maintained on ASA but had recurrent bleeding. During these admissions he decided that he was not interested in heart transplantation. He was removed from the UNOS waitlist and his status was switched to VAD as DT. He was readmitted with VAD stoppage, low flows, high powers and chocolate colored urine. LDH>1500 and decreased hemoglobin. He was a poor surgical candidate, declined anticoagulation .He had minimal myocardial recovery with persistent severe LV dysfunction (EF ～ 10%). He was felt to be too ill to undergo VAD explant surgery. Thus, the VAD was deactivated, inflow cannula and outflow grafts left in situ and the drive line severed and surgically buried. A ～10-12 cm remnant was buried under the skin (figure). Skin incision was closed primarily. The original exit site was left to heal by secondary intention. The wound completely healed. Luckily, patient continued to do well. Almost a year after VAD inactivation, he developed skin irritation at the site of prior driveline site. He delayed contacting us and presented to clinic with a severe soft tissue infection (Enterobacter cloacae and Staph aureus) at the old driveline site. He required surgical debridement, excision of the driveline, IV antibiotics and a wound-vac. The drive line site is healing well afterwards. DiscussionOne sees a drive line site infection in VAD patient's, but our case highlights the fact that even if the drive line has been excised and stump buried under the skin, a delayed infection like ours, though unlikely, is still possible.Our case also highlights the fact that leaving all the VAD apparatus in patients who are high risk for explant is a safe option, as our patient continues to do well a year after his VAD deactivation.