Stomach Pierced by Apical Cuff late after Removal of Toyobo Assist Device
Kan Nawata, PhD,
Shunei Kyo, PhD,
Minoru Ono, PhD,
Noboru Motomura, PhD,
Shinichi Takamoto, PhD
Department of Cardiothoracic Surgery Faculty of Medicine, University of Tokyo Tokyo, Japan
Kan Nawata, PhD Tel: +81 3 5800 8654 Fax: +81 3 5684 3989 Email: knawata-tky{at}umin.ac.jp, Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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ABSTRACT
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A 38-year-old woman suffering from dilated cardiomyopathy underwent successful removal of a Toyobo left ventricular assist device after 11 months of support. Four months later, discharge of pus from the skin resulted from the contaminated residual apical cuff. The purulence stopped spontaneously 16 months later, but halitosis then developed. Two weeks later, fever and hematemesis occurred. Emergency surgery revealed gastric perforation by the apical cuff, which was removed under cardiopulmonary bypass.
Key Words: Cardiomyopathy • Dilated • Gastric Fistula • Heart-Assist Devices
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INTRODUCTION
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The Toyobo (Toyobo Co., Osaka, Japan) is a paracorporeal pneumatic left ventricular assist device (LVAD) and one of the most prevalent types of LVAD in Japan.1 On installment, an apical cuff made of polyester and silicon is attached to the apex, and a drainage tube is inserted and fixed through the cuff (Figure 1
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Figure 1. Schema and outer appearance of the Toyobo left ventricular assist device, which is paracorporeal and pneumatic. The perfusion graft is anastomosed to the ascending aorta, and the drainage tube is fixed through the cuff which is sutured to the apex.
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CASE REPORT
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A 37-year-old woman with severe congestive heart failure due to dilated cardiomyopathy was fitted with a Toyobo LVAD. After 11 months of medication and physical training, she was successfully weaned from the LVAD without CPB support. The procedure involved truncation of the ascending aortic perfusion tube with closure and suturing of its stump, removal of the apical drainage tube, and suture closure of the aperture of the cuff. She was discharged 58 days later with no sign of a major complication. Four months later, a discharge of pus from the residual subcutaneous tunnel of the drainage tube was noted. Fistulectomy under general anesthesia was tried, which revealed bacterial contamination (Staphylococcus epidermidis) of the apical cuff. At that point, considering her poor general condition, we treated the discharge conservatively. She left hospital on oral clindamycin; her white blood cell count was 3.4 x 103 · mm–3 and serum C-reactive protein was 0.19 mg · dL–1. Pus discharge from the fistula stopped spontaneously 16 months later. No episode of fever was observed, and laboratory data showed no inflammatory signs. One week later, fever of over 38°C developed, together with nausea and hematemesis. Two weeks later, at our outpatient clinic, the patient vomited approximately 200 mL of brown blood. She had no abdominal pain, but complained of halitosis. Emergency gastric fibroscopy revealed a minor submucosal hemorrhage at the esophagogastric junction, but no sign of active bleeding, although thorough observation was difficult because of her severe nausea. Computed tomography performed after gastroscopy revealed an air-filled space around the apical cuff, communicating with the gastric internal lumen (Figure 2). Gastric perforation was suspected, and an urgent operation was performed the next day. An incision was made in the 6th left intercostal space, followed by a connecting parasternal incision. The gastric wall covered the apical cuff which penetrated the wall. The closed end of the cuff was extracted from the gastric wall, and the tear was repaired. CPB was established via left femoral cannulation. Under induced ventricular fibrillation, the apical cuff with an infected thrombus inside it was removed completely along with the other artificial materials. The apical hole was closed securely with running nonabsorbable monofilament sutures, and the suture line was covered with an omental flap. Weaning from CPB was easy. Part of the skin incision was left open for drainage. Submitted specimens were all positive for Staphylococcus epidermidis and alpha-streptococci on bacterial culture. Postoperative drainage was negative for bacteria, the white blood cell count was 3.3 x 103 · mm–3, and serum C-reactive protein was 0.17 mg · dL–1 when the patient left the hospital 23 days after the operation.
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Figure 2. Computed tomography showing the apical cuff penetrating the gastric wall. Note the air bubbles around the cuff and the thrombus within it (white arrows).
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DISCUSSION
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This was a rare case in which infection at the apical cuff eventually led to gastric perforation and hematemesis. When the patient was weaned from the LVAD, no sign of infection was detected at the apical cuff or the drainage tube site. However, inside the residual cuff, a thrombus could easily form, which would be susceptible to infection. Considering that 4 months passed before the skin fistula first appeared, some intra- or postoperative bacterial contamination may have caused infection of the cuff and the thrombus inside it. The spontaneous interruption of pus drainage through the skin may be considered to have resulted from a newly established drainage route for the pus into the stomach. The fact that the patient’s halitosis disappeared postoperatively confirms this speculation.
A further concern regarding this patient is that a piece of artificial graft is still attached to her ascending aorta. There has been a previous report of a case in which a residual graft caused an ascending aortic pseudoaneurysm.2 Thus, careful follow-up is needed. This case suggests that the apical cuff should be removed with the aid of CPB on weaning from a Toyobo LVAD. Otherwise, an alternative mechanism should be devised to prevent thrombus formation in the residual apical cuff.3
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ACKNOWLEDGMENTS
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The authors are grateful to Mr. CWP Reynolds for his careful revision of the English of this manuscript.
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REFERENCES
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- Kyo S, Nishimura M, Asano H. Left ventricular assist system [Review]. Nippon Geka Gakkai Zasshi 2002;103:597–602.[Medline]
- Omoto T, Minami K, Muramatsu T, Kyo S, Körfer R. Pseudoaneurysm after heart transplantation with history of LVAD driveline infection. Ann Thorac Surg 2001;72:263–4.[Abstract/Free Full Text]
- Komoda T, Komoda S, Dandel M, Weng Y, Hetzer R. Explantation of INCOR left ventricular assist device after myocardial recovery. J Card Surg 2008;23:642–7.[Medline]
Asian Cardiovasc Thorac Ann 2010;
18:74-76
© 2010 by SAGE Publications
DOI: 10.1177/0218492309352537
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ABSTRACT
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