title: Surgical Treatment of Mediastinitis with Omentoplasty in Ventricular Assist Device Patients: Report of Referral Center Experience.
abstract: Mediastinitis is more frequent in patients with implantable ventricular assist devices (VADs) than in other cardiac surgery patients and carries significant mortality. We report our experience with a stepwise approach including aggressive debridement, jet lavage, vacuum assisted closure dressing, and finally coverage with well-vascularized and immune-active omental flaps in VAD patients with infective mediastinitis. We retrospectively collected and analyzed data of patients with continuous flow VAD who underwent plasty with the omental flap because of mediastinitis at Deutsches Herzzentrum Berlin between January 1, 2008 and October 30, 2015. Eight hundred forty-five patients underwent VAD implantation during the study period. Omentoplasty due to infective mediastinitis was performed in 17 cases. Nine had a HeartWare HVAD as left ventricular assist device (LVAD), three patients had two Heart-Ware HVAD as biventricular assist device (BIVAD), four had a HeartMate II LVAD device, and one patient had a Berlin Heart Incor LVAD. The microorganisms most frequently isolated from the sternal wound were Gram-positive Staphylococcus spp. Four cases of bleeding requiring surgical revision were recorded: three of intraabdominal and one of wound bleeding. Eight patients (47%) survived, whereas the other nine patients (53%) died. Sixteen (94%) required intensive care unit admission, and median hospital stay was 21 (1-182) days. Postoperative renal failure requiring dialysis and septic shock requiring vasopressors were associated with hospital mortality (p = 0.009 and p = 0.05, respectively). Early surgical treatment of mediastinitis after VAD implantation with omentoplasty is a valuable strategy in an otherwise dead-end situation. Bleeding should be meticulously controlled in these anticoagulated and fragile patients.
authors.affiliation: From the *Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; †Department for Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; ‡DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany; §Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany; and ¶Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany.
authors.forename: Marina
authors.initials: M
authors.lastname: Pieri
authors.forename: Marcus
authors.initials: M
authors.lastname: Müller
authors.forename: Anna Mara
authors.initials: AM
authors.lastname: Scandroglio
authors.forename: Panagiotis
authors.initials: P
authors.lastname: Pergantis
authors.forename: Alexandra
authors.initials: A
authors.lastname: Kretzschmar
authors.forename: Friedrich
authors.initials: F
authors.lastname: Kaufmann
authors.forename: Volkmar
authors.initials: V
authors.lastname: Falk
authors.forename: Thomas
authors.initials: T
authors.lastname: Krabatsch
authors.forename: Georg
authors.initials: G
authors.lastname: Arlt
authors.forename: Evgenij
authors.initials: E
authors.lastname: Potapov
authors.forename: Marian
authors.initials: M
authors.lastname: Kukucka
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000601:surgery*; D008875:Middle Aged; D009852:Omentum / Q000601:surgery*; D012017:Referral and Consultation; D012189:Retrospective Studies; D016896:Treatment Outcome