Universidad Autonoma de Madrid
Correspondence to: Evaristo Castedo, MD, Department of Cardiothoracic Surgery, Clínica Puerta de Hierro, c/San Martín de Porres 4. 28035 Madrid, Spain; e-mail: email@example.com
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,1and 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
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
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