gms | German Medical Science

Introduction: We report the case of a 51-year-old patient who had received a left ventricular assist device (LVAD) (Incor™, Berlin-Heart, Berlin, Germany) two previously as destination therapy. He now presented with an infected full thickness defect in the left lateral thoracic wall caused by the continuous movement of the LVAD leading to erosion of the rib.

The patient had suffered several wound healing complications after LVAD implantation, including recurring drive-line infections treated conservatively and surgically as well as presternal VACUSEAL-therapy with secondary wound closure.

The patients constitution was rather skinny, he had a body weight of 66 kg at a height of 181 cm and a body mass index of 20 kg/m². thus after two and a half years the LVAD started to erode parts of the 7th rip and subsequently protruded through the skin (Figure 1). After perforation the 5x3cm large wound got infected.

As the patient was not eligible for heart transplantation due to severe compliance problems, an alternative treatment was performed: The Assist Device was covered with a pedicled latissimus dorsi muscle flap.

Material and methods: The area surrounding the LVAD was debrided carefully by an extra thoracic approach to avoid repeat sternotomy, this lead to a wound size of 9x5cm. Histological examination of the resected tissues revealed bone erosion and osteomyelitis of the 7th rip. A synthetic mesh (Ultrapro by Ethicon Inc., Sumerville USA) was then inserted to reduce the risk of re-perforation of the device. This was followed by a pedicled latissimus dorsi muscle flap with a skin paddle of 13x5cm to cover the defect. Specific antibiotic treatment was administered. On the intensive care unit continuous coagulation therapy using heparin had to be re-initiated due to the LVAD, aiming at a PTT of 70 seconds. This unfortunately led to some diffuse wound bleeding requiring surgical revision on the next day, no major surgical cause was detected. Anticoagulation therapy was aiming at PTT levels between 50 sec thereafter. During the following days and weeks he was carfully mobilized, oral anticoagulation therapy was adjusted and he was finally discharged from the hospital on the 34^th day.

Results: The major postoperative problem was to balance the coagulation management in a patient with large wounds leading to a high bleeding risk and need for continuous anticoagulation therapy due to LVAD therapy.

We applied compression therapy with a thorax belt on the large wound surface of the donor site directly after surgery and reduced the goal of anticoagulation to PTT of 50 seconds. Fortunately no device dysfunction occurred and no bleeding events occurred thereafter.

Wound inspection revealed a completely covered LVAD and a well-healed latissimus dorsi muscle flap at the time of discharge. The patient had a normal further course without any wound healing problems for the consecutive three months. Thereafter he died suddenly due to other medical conditions.

Conclusion: In conclusion the pedicled latissimus dorsi flap is an excellent option to cover lateral thoracic defects with an exposed LVAD. An interdisciplinary team consisting of plastic and cardiac surgeons, critical care specialists, cardiologists and microbiologists is needed to treat these highly demanding patients sufficiently.

Perforating Assist Device with pedicled latissimus dorsi muscle flap