Surgical wound complications after heart transplantation

Abstract

Surgical wound complications are more frequent in patients undergoing heart transplantation than in other heart surgery patients. This is probably attributed to the presence of additional risk factors in these patients, such as immunosuppression, mechanical support through assist devices and generally poor health. Analyses of wound infections in heart transplantation are based on smaller patient population than those for general heart surgery, and the reported incidences vary largely. The identification of specific risk factors in heart transplant recipients to date is mainly based on retrospective case-control studies in small patient cohorts, the results are controversial, and the comparability of data is limited because of the lack of application of consistent definitions. The impact of immunosuppression and especially immunosuppression with mammalian target of rapamycin (mTOR) inhibitors on the development of surgical wound complications has been widely discussed following reports of increased occurrence with sirolimus. However, nonheart-transplant specific risk factors should also be considered to develop risk profiles and treatment algorithms for individual patients. Data on surgical wound complications in general heart surgery patients and in heart transplant recipients are compared, the impact of modern immunosuppression reviewed, and areas for further investigation discussed.

Everolimus and sirolimus in transplantation-related but different

“…All but one [70] of the analyses that present information on adverse events in patients receiving sirolimus or everolimus was undertaken in maintenance patients [71–73,75], such that information on healing of the transplant incision is virtually absent. Two reviews summarized the results of controlled studies with either sirolimus or everolimus in kidney [86] and heart [87], based on which it appears that the rate of surgical wound healing complications is lower with everolimus. In none of the phase III trials with everolimus in de novo renal transplantation an increase in wound healing complications was observed [88–90].…”

Drugs for the Prevention and Treatment of Cardiac Allograft Vasculopathy

“…In a large cohort of maintenance heart transplant recipients taking a PSI, 16% withdrew treatment in the first year, and 25% had stopped PSI due to severe adverse events by the fourth year [59]. These adverse effects include but are not limited to [60], peripheral lymphedema [61], debilitating aphthous ulceration [62], wound dehiscence and impaired wound healing [63], hyperlipidemia [64], pneumonitisand anemia [66].…”

Everolimus in Heart Transplantation: An Update

“…The potential risk of impaired wound healing and fluid retention at operative sites indicates that delayed initiation of everolimus after transplantation (e.g., approximately 8–14 days) or after other surgical interventions may be helpful although such an approach has shown no benefit in kidney transplantation [51]. Delayed introduction of everolimus has not yet been systematically explored in heart transplantation but may be most relevant in heart transplant patients with risk factors for poor healing, particularly obesity or diabetes, and in patients with previous coronary artery bypass grafting with bilateral harvesting of the mammarial arteries or those undergoing re-thoracotomy early after transplantation [13, 52]. …”