Escalating Surgical Treatment for Left Ventricular Assist Device Infection and Expected Mortality: Clinical Risk Prediction Score.

BACKGROUND: Left ventricular assist devices (LVAD) improve survival for patients with cardiac failure, but LVAD specific infections (VSI) remain a challenge with poorly understood predictive risk factors. Furthermore, the indications and utility of escalating medical treatment to surgical debridement and potential flap reconstruction are not well-characterized. STUDY DESIGN: A retrospective review of consecutive patients undergoing primary LVAD implantation at a tertiary academic center was performed. The primary outcomes measures were 90-day and overall mortality after VSI. Cox proportional hazards regression was used to generate a risk-prediction score for mortality. RESULTS: Of the 760 patients undergoing primary LVAD implantation, 255 (34%) developed VSI; of these 91 (36%) were managed medically, 134 (52%) with surgical debridement, and 30 (12%) with surgical debridement and flap reconstruction. One-year survival after infection was 85% with median survival of 2.40 years. Factors independently associated with increased mortality were diabetes (hazard ratio (HR) 1.44, p=0.04), methicillin-resistant Staphylococcus aureus infection (HR 1.64, p=0.03), deep space (pump pocket/outflow cannula) involvement (HR 2.26, p<0.001) and extra-corporeal membrane oxygenation after LVAD (HR 2.52, p<0.01. Factors independently associated with decreased mortality were flap reconstruction (HR 0.49, p=0.02) and methicillin-sensitive Staphylococcus aureus infection (HR 0.63, p=0.03). A clinical risk prediction score was developed using these factors and showed significant differences in median survival, which was 5.67 years for low-risk (score 0-1), 3.62 years for intermediate-risk (score 2), and 1.48 years for high-risk (score >3) (p<0.001) patients. CONCLUSIONS: We developed a clinical risk prediction score to stratify VSI patients. In selected cases, escalating surgical treatment was associated with increased survival. Future work is needed to determine if early surgical debridement and flap reconstruction can alter outcomes in select cases of VSI.

Recurrent Compartment Syndrome Leading to the Diagnosis of McArdle Disease: Case Report.

Glycogen storage disorders are rare diseases of metabolism that are usually diagnosed when a patient presents with recurrent fatigue, muscle pains, and exercise intolerance. In this case report, we describe a patient who presented with the second episode of nontraumatic compartment syndrome over a 10-year span. Because of the obscure presentation, we performed a muscle biopsy, which on muscle phosphorylase staining revealed McArdle disease (glycogen storage disease type V).

Anterolateral thigh flow-through flap in hand salvage.

OBJECTIVE: Hand salvage and reconstruction following trauma and oncologic resection often dictates the use of innovative reconstructive techniques. Preservation of functional anatomy is paramount to success in this clinical setting. Further constraints are placed on the reconstructive surgeon in the setting of the aging US population. We report a case of successful hand salvage in an elderly patient using a free anterolateral thigh flow-through flap. METHODS: A retrospective chart review was performed on prospectively entered data to examine the case in detail. Indications, radiographs, and follow-up visits were reviewed. A free anterolateral thigh flap was harvested and used to provide soft tissue coverage as well as reconstruction of the palmar arch. RESULTS: The free anterolateral thigh flap not only reconstructed the unique soft tissue envelope of the hand but also restored functional vascular anatomy by reconstituting the interrupted superficial palmar arch. The patient had an uneventful hospital course and was discharged without complications. CONCLUSIONS: The free anterolateral thigh flap is a versatile flap that can be used as an innovative solution for hand salvage where vascular anatomy and soft tissue need to be restored.