Bilateral pectoralis major flaps for salvage of left ventricular assist device deep pocket infection

Abstract

Current treatment for end-stage cardiac disease has benefitted greatly from the development of left ventricular assist devices (LVADs). However, as the prevalence of LVADs increased, so too did the number of patients with complications. The smaller size of the HeartMate III (HMIII) device allows for it to be placed completely intrathoracic. This requires a new reconstructive strategy when deep pocket infection and hardware exposure ensue. We report our first case of flap coverage of an exposed HMIII after deep pocket infection and discuss the reconstructive challenges associated with this fully intrathoracic device. A 31-year-old female with worsening postpartum non-ischemic cardiomyopathy was transferred to our facility in end-stage heart failure. She underwent complete sternal-sparing placement of a HMIII via bilateral anterior thoracotomies, and eventually developed a deep pocket infection with intrathoracic abscess. Plastic Surgery reconstructed the wounds using bilateral pectoralis major muscle flaps. The patient enjoyed an uneventful postoperative course and was discharged home 2 weeks later on intravenous antibiotics. HMIII devices are completely intrathoracic, occupying the pericardial space anteriorly, which can make an infection difficult to access. Wound location largely dictated which flaps would be acceptable for reconstruction following debridement. Close cooperation between cardiac and reconstructive surgeons will once again be paramount to evolving the surgical care of HMIII patients with deep pocket infection.

Level of Evidence: Level V, therapeutic study.

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Correspondence to Jose G. Christiano.

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Drew C. Mitchell, Brian Ayers, Alap U. Patel, Miranda A. Chacon, Katherine Wood, Bryan Barrus, Sunil M. Prasad, Igor Gosev, and Jose G. Christiano declare that they have no conflict of interest.

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Mitchell, D.C., Ayers, B., Patel, A.U. et al. Bilateral pectoralis major flaps for salvage of left ventricular assist device deep pocket infection. Eur J Plast Surg 43, 97–102 (2020). https://doi.org/10.1007/s00238-019-01554-6

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Keywords

  • Left ventricular assistance device LVAD
  • Infection
  • Plastic and reconstructive surgery
  • Cardiothoracic surgery
  • Heartmate
  • Pectoralis major flap