From the Divisions of Plastic Surgery.
Cardiothoracic Surgery, Department of Surgery, University of Rochester, Rochester, NY.
Ann Plast Surg. 2023 Jun 1;90(6S Suppl 5):S552-S555. doi: 10.1097/SAP.0000000000003408. Epub 2022 Dec 21.
The use of left ventricular assist devices (LVADs) for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Poor data exist to determine how to manage these infections after operative debridement.
Patients who underwent insertion of a ventricular assist device and had a subsequent readmission for LVAD infection at the University of Rochester Medical Center from 2012 to 2022 were identified through accessing the medical records archives of the hospital. Patients were followed retrospectively for an average of 3.2 years. Patient demographics, preoperative diagnosis/disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, infectious organism identified at initial washout, infectious organism identified at time of definitive device coverage, timing of coverage procedure after the initial washout for infection, type of flap used for coverage, 90-day complications after definitive coverage, and lifetime return to operating room for infection were reviewed. Comparison analysis with a χ 2 test was used to analyze outcomes.
Of 568 patients admitted with an LVAD-related infection 117 underwent operative debridement. Of these, 34 underwent primary closure, 31 underwent closure with secondary intention (negative pressure wound therapy with split thickness skin grafting), and 52 were closed with a flap (pectoralis, omental, latissimus, or vertical rectus abdominus musculocutaneous flap). There was a statistically significant higher incidence of return to the operating room (RTOR) for infection over a lifetime with primary closure compared with secondary intention and flap reconstruction ( P = 0.01, 0.02), but no difference in 90-day complications ( P = 0.76, P = 0.58). Eighty-three patients had a positive culture upon definitive coverage with 24 having a postsurgical complication, 15 of which required lifetime RTOR for infection. Thirty four were closed with negative cultures with 9 having a complication and 4 requiring RTOR for infection. This was not statistically significant for complications or RTOR ( P = 0.79, 0.40). Culture data were further substratified into bacterial cultures (n = 73) versus fungal cultures (n = 10), and there was no statistically significant difference between these compared with complications or RTOR ( P = 0.40, 0.39).
Coverage of infected LVADs with locoregional flaps or allowing to granulate using wound vac therapy has a decreased lifetime RTOR for future infections for these patients without increase in 90-day complications. Timing of RTOR should not be impacted by positive cultures provided there is healthy granulation tissue in the wound.
使用左心室辅助装置（LVAD）治疗等待心脏移植的终末期心力衰竭患者已变得越来越普遍。然而，与心室辅助装置相关的感染仍然是一个主要问题，使其长期使用复杂化。目前的数据不足以确定在手术后清创后如何处理这些感染。
通过访问医院的病历档案，确定了 2012 年至 2022 年在罗切斯特大学医学中心接受心室辅助装置植入术并随后因 LVAD 感染再次入院的患者。对患者进行了平均 3.2 年的回顾性随访。患者的人口统计学特征、术前诊断/疾病状态、植入的心室辅助装置类型、心室辅助装置感染发作的术后天数、初次冲洗时鉴定的感染病原体、明确装置覆盖时鉴定的感染病原体、初次冲洗后覆盖程序的时间、用于覆盖的瓣类型、明确覆盖后 90 天的并发症以及终生因感染返回手术室的情况均进行了回顾。使用 χ 2 检验进行了比较分析。
在 568 名因 LVAD 相关感染而入院的患者中，有 117 名患者接受了手术清创。其中，34 例行一期缝合，31 例行二期缝合（负压伤口治疗联合皮片移植），52 例行瓣覆盖（胸大肌、网膜、背阔肌或垂直腹直肌肌皮瓣）。与二期缝合和瓣重建相比，一期缝合的终生感染再次手术率（RTOR）有统计学意义（ P = 0.01，0.02），但 90 天并发症无差异（ P = 0.76， P = 0.58）。在明确覆盖时，83 例培养阳性，24 例术后并发症，其中 15 例需要终生 RTOR 治疗感染。34 例培养阴性，9 例发生并发症，4 例因感染需要 RTOR。并发症或 RTOR 无统计学意义（ P = 0.79，0.40）。进一步对培养数据进行细菌培养（n = 73）和真菌培养（n = 10）的亚组分析，与并发症或 RTOR 相比，差异无统计学意义（ P = 0.40，0.39）。
对于这些患者，用局部瓣覆盖感染的 LVAD 或允许使用伤口真空疗法形成肉芽组织，可降低未来感染的终生 RTOR，而 90 天的并发症无增加。只要伤口有健康的肉芽组织，RTOR 就不应受培养阳性的影响。
