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Universidad Autonoma de Madrid Madrid, Spain
Correspondence to: Evaristo Castedo, MD, Department of Cardiothoracic Surgery, Clínica Puerta de Hierro, c/San Martín de Porres 4. 28035 Madrid, Spain; e-mail: ecastedom{at}terra.es
To the Editor:
Infectious complications are, with rejection, the main cause of morbidity and mortality in recipients of heart transplantation (HT). Between September 1984 and October 2000, we performed 514 HTs in 505 patients; of these, postoperative mediastinitis developed in 7 patients (1.4%). The mortality rate in this group of patients was 42%.
Surgery, combined with antibiotic therapy and temporary reduction of immunosuppression, can successfully treat sternal wound infection after HT. Debridement irrigation technique has a low success rate,1 and usually a more aggressive technique is required. The use of a pedicled omental flap based on the right gastroepiploic artery appears to provide adequate bulk for obliteration of the large dead space that remains after debridement, and for us is the treatment of choice because of its greater rate of success.2 3
Nevertheless, omentoplasty, though effective and useful in treating mediastinitis, is also a relative contraindication for future cardiac reinterventions through median sternotomy. The omental tissue has an excellent blood supply that limits spread of infection but also has perfect adhesive properties that promote strong pericardial adherences and new vascular anastomosis with adjacent vessels,4 which make future repeat sternotomy a real surgical challenge that no cardiac surgeon would like to face. Right or left thoracotomy may be a good alternative approach for these patients if coronary artery bypass grafting or valve surgery is to be performed, but not for other complex surgical procedures in which median sternotomy is mandatory.
We present a case of a 33-year-old man who developed bacterial mediastinitis and sternal dehiscence after orthotopic HT. He underwent prompt sternal debridement, and a transposition of the greater omentum to the thorax was performed. One month later, he was discharged in satisfactory condition. Nine years after HT, he was readmitted to hospital with congestive heart failure and low cardiac output. Cardiac catheterization revealed a left ventricle ejection fraction of 14% and a normal pulmonary artery pressure. Neither angiography nor intracoronary ultrasound study could demonstrate any gross stenosis in the epicardial coronary vessels. MRI showed no calcified or thick scar tissue in the retrosternal space. The diagnosis of late graft failure probably secondary to microvascular disease was established. Despite the great operative risk of cardiac retransplantation5 and cardiac surgery after a previous omentoplasty, he was accepted for retransplantation. Surgery was performed 6 months later through a median sternotomy. Extremely careful dissection of pericardial adherences and the use of intraoperative aprotinin and a cell-saving device were necessary to minimize blood loss. The total ischemic time of the organ was 195 min. Total postoperative blood loss was 500 mL. The patient’s postoperative course was uneventful, and he was discharged 3 weeks later in a satisfactory condition.
In conclusion, omentoplasty for previous mediastinitis should not be considered a major contraindication for cardiac retransplantation. Surgery is complex but technically feasible. Absence of significant thick scar tissue and calcification within the retrosternal space in the MRI may be a good indicator that the procedure can be performed safely.
References
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