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).