Combined Heart Transplantation and Latissimus Dorsi Myo-Cutaneous Flap as Ultima Ratio Due to Severe Osteomyelitis Following LVAD Implantation and Total Sternectomy

Abstract

<h3>Introduction</h3> Infections in LVAD-patients are common and may lead to life-threatening complications. Although driveline infections are most commonly detected, development of blood stream infections related to LVAD-implantation can also pilot towards mediastinitis and osteomyelitis, thus resulting in extensive bone destruction of the sternum. <h3>Case Report</h3> A 37-year-old patient was transferred to our heart failure unit following complete sternectomy due to severe osteomyelitis, mediastinitis and a pyopericardium three years after an emergent LVAD implantation. An LVAD weaning was not possible due to immediate compromise of hemodynamics. The patient presented a thorax apertum secured in vacuum therapy and persistent wound infection with 3 MRGN positivity. Through intensified antibiotic therapy, continuous wound dressing and renewal of vacuum therapy, the infection was controlled, and a stable status achieved. After excluding contraindications for heart transplantation (HTx), the patient was accepted for a high-urgency transplantation and successfully transplanted one month later. Thereupon, the thorax was surgically reconstructed using an extended, right-sided latissimus-dorsi, myo-cutaneous flap. Relevant hemorrhage and partial repositioning of the flap was surgically approached two weeks after the initial procedure. Antibiotic treatment was continued to prevent superinfection and modified due to postoperative pneumonia and coloproctitis. The latissimus plastic showed continuous serous perfusion without inflammation, which was drained once weekly in an external clinic for two months. Echocardiography showed preserved biventricular function. Myocardial biopsies detected no higher-grade rejection as immunosuppression was established. After achieving full recovery, the patient was successfully discharged. <h3>Summary</h3> Extended and undetected osteomyelitis can rapidly lead to life-threatening mediastinitis and sepsis. Whenever inflammation parameters remain elevated, osteomyelitis should always be considered as a focus of infection on patients following LVAD-implantation. A combined heart transplantation and latissimus-dorsi plastic present a viable option for defect coverage and a possible long-term solution after extensive sternal resection in LVAD patients.