The use of muscle flaps to treat left ventricular assist device infections

Left ventricular assist devices have become an important adjunct in the the rapeutic armamentarium for patients with end-stage heart failure. Although they may provide a bridge to transplantation, they are prone to certain pro blems, expecially infection. Because these are life-sustaining devices, cha nging the device or simple explantation may be a risky, if not impossible, option. Therefore, we evaluated the effectiveness of a surgical alternative , namely, coverage of infected devices with muscle or myocutaneous flaps. Eighty-two consecutive patients who underwent the insertion of 88 left vent ricular assist devices at our institution over a 6.5-year period were evalu ated. Follow-up was provided for all patients and ranged from 1 to 7.5 year s. The duration of ventricular support ranged from 0 to 434 days. All patie nts who demonstrated clinical evidence of infection were identified. Over a ll, 54 patients (66 percent) had infections locally at the device site, at distant sites, or systemically during support. Cultured organisms included gram-positive and -negative bacteria, fungi, and viruses. Of the 56 infecti ons in these 54 patients, 21 (38 percent) were device-related, i.e., in the pocket created by the device, in the device itself, or from the driveline. Thus, 24 percent (21 of 88) of all ventricular support devices inserted de monstrated device infection during use. Therapeutic modalities used to combat device-related infection included bot h nonsurgical management with antibiotics alone and surgical procedures suc h as device change or relocation; device explant, and flap coverage. Eight of the 20 patients in whom the 21 device-related infections occurred underw ent surgical intervention. Four of these eight patients underwent local fla p coverage of their infected left ventricular assist devices. All foul pati ents also had evidence of systemic infection, or "device endocarditis." Cov erage was successfully achieved in all cases with pedicled rectus abdominis flaps. There were no perioperative complications. Two patients later under went successful transplantation; the other two died from causes unrelated t o the flap. In conclusion, the treatment of infected left ventricular assist devices cu rrently includes both nonsurgical and surgical alter-natives. Of the latter , muscle flaps should be considered a first-line intervention to assist in eradicating infection by providing well-vascularized tissue. Although there were no perioperative complications, the 50 percent mortality rate is cons istent with that reported for patients with "device endocarditis." It may b e that flap coverage of infected ventricular assist devices, if instituted at an earlier stage in the therapeutic process, could help prevent systemic infection in these patients and, therefore, improve their overall outcome.