Recent history and post-transplant assessment
A 66-year-old male patient underwent OHT due to dilated ischemic cardiomyopathy previously treated elsewhere with multiple procedures including coronary artery bypass and left ventricular assist device (HeartWare®). OHT was performed in July 2013. Basiliximab was administered as inductive immunosuppression, followed by maintenance immunosuppression consisting of tacrolimus, mycophenolat-mofetil and prednisone. Co-morbidities included chronic gastritis, amiodarone-induced subclinical hypothyroidism, type-II diabetes mellitus, kidney cysts and chronic prostatitis, which all were well controlled. The post-transplant period was complicated by bilateral exudative pleuritis, thrombosis of right internal jugular vein, neutropenia and persistent sinus bradyarrhythmia with implantation of a two-chamber pacemaker using the left cephalic vein.
Thirty-seven days after OHT, progressive infection of the median sternotomy wound with a greyish-yellow discharge was noted starting at the epigastrium and resulting in complete skin necrosis and wound dehiscence with direct view on the transplanted heart. However, no microorganisms were identified on standard blood cultures. CT-scan reported pneumomediastinum and a left-sided hydropneumothorax of 300ml at the site of the previous LVAD, compressing the fibrotic left lower lung lobe.
The patient was referred to our clinic 43 days after OHT pre-treated with meropenem, vancomycin, linezolid, tigecycline, fluconazole and voriconazole. At clinical examination, the fully awake and neurologically normal patient was breathing spontaneously but presented in poor general condition, malnourished (serum albumin 16g/L) and with renal insufficiency (creatinine 150 µmol/l).