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The plastic surgeon’s role in managing ventricular assist device (VAD) complications: a single institution experience of 397 VADs
Michael N. Mirzabeigi, Shareef Jandali, MD, Stephen J. Kovach, MD, David W. Low, MD, Joseph M. Serletti, MD, Suhail Kanchwala, MD.
University of Pennsylvania, Philadelphia, PA, USA.
BACKGROUND: As the need for orthotopic heart transplant outstrips the available supply of donor organs, ventricular assist devices (VADs) have a prominent role in the treatment of end-stage heart failure. VADs, once reserved to transiently bridge patients to transplant or recovery, are now often indefinitely placed to serve as lifelong, “destination therapy”. Given the increasing frequency and lengths of time in which VADs are placed, device-related complications have correspondingly increased. The purpose of this study is to explore the techniques utilized in the plastic surgery armamentarium and subsequent outcomes when addressing VAD complications.
METHODS: A retrospective chart review of hospital and office records was performed on all patients undergoing VAD placement from January 1997 to June 2010.
RESULTS: From January 1997 to June 2010, 397 VADs were placed. Of all VADs, 11 required intervention by plastic surgery services in the following manner: complex closure following initial VAD placement (1), salvage of exposed/infected devices (7), and management of VAD pockets following device removal (3). Flaps utilized for the abovementioned purposes included: omental flap (3), external oblique flap (1), rectus flap (4), and the remaining three patients were consulted for debridement and definitive closure. In cases of device salvage, the mean time from VAD placement to plastic surgery intervention was 35 days (range 20 - 72), however only 29 percent of these patients eventually received organ transplant. In the final three years of study, the number of destination VADs increased 275 percent in comparison to the preceding equivalent time period.
CONCLUSIONS: A wide range of surgical solutions are required in order to properly manage VAD patients given the variation in VAD placement, type of complication, and patients’ prior surgical history. Particularly given the recent evidence of biofilms and ascending driveline infections, aggressive and timely intervention can provide lifesaving measures. Plastic surgeons should be familiar with the armamentarium at their disposal when approaching these challenging cases as this stands to become an increasingly prevalent issue.
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