Aortic root abscesses are severe sequelae of endocarditis that clinically manifest as life-threatening infection. As the opioid epidemic continues to yield a national crisis, the incidence and severity of this disease process have increased. Reconstruction of the aortic root is a challenging undertaking and carries the risk of recurrent infection. The omentum has an established reputation as a reliable flap in thoracic reconstruction, given its amorphous form and immunogenic properties, but it has not been utilized for aortic root infections. We present a novel indication for the omental flap using a cardioplastic approach in coverage of aortic root reconstruction. Four patients were treated with pedicled omental flap coverage after aortic root reconstruction. All patients had successful flap healing with no evidence of recurrent infection. This series demonstrates the technical feasibility and clinical utility for providing soft tissue coverage and antimicrobial protection when used in aortic root reconstruction

Bonaroti, Alisha R.

DeCoster, Ryan C.

Edmunds, R. Wesley

Liau, James Y.

Sekela, Michael E.

Vasconez, Henry C.

English

University of Kentucky

University of Kentucky UKnowledge Surgery Faculty Publications Surgery 10-2020 Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era Alisha R. Bonaroti University of Kentucky, abonaroti@uky.edu R. Wesley Edmunds University of Kentucky Ryan C. DeCoster University of Kentucky, rcde223@uky.edu James Y. Liau University of Kentucky, jyliau0@uky.edu Michael E. Sekela University of Kentucky, mese223@uky.edu See next page for additional authors Follow this and additional works at: https://uknowledge.uky.edu/surgery_facpub  Part of the Surgery Commons Right click to open a feedback form in a new tab to let us know how this document benefits you. Repository Citation Bonaroti, Alisha R.; Edmunds, R. Wesley; DeCoster, Ryan C.; Liau, James Y.; Sekela, Michael E.; and Vasconez, Henry C., "Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era" (2020). Surgery Faculty Publications. 42. https://uknowledge.uky.edu/surgery_facpub/42 This Article is brought to you for free and open access by the Surgery at UKnowledge. It has been accepted for inclusion in Surgery Faculty Publications by an authorized administrator of UKnowledge. For more information, please contact UKnowledge@lsv.uky.edu. Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era Digital Object Identifier (DOI) https://doi.org/10.1097/GOX.0000000000003197 Notes/Citation Information Published in Plastic and Reconstructive Surgery--Global Open, v. 8, issue 10, e3197. Copyright © 2020 The Authors This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Authors Alisha R. Bonaroti, R. Wesley Edmunds, Ryan C. DeCoster, James Y. Liau, Michael E. Sekela, and Henry C. Vasconez This article is available at UKnowledge: https://uknowledge.uky.edu/surgery_facpub/42 Downloadedfromhttp://journals.lww.com/prsgobyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78=on12/15/2020Downloadedfromhttp://journals.lww.com/prsgobyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78=on12/15/2020 www.PRSGlobalOpen.com 1Related Digital Media are available in the full-text  version of the article on www.PRSGlobalOpen.com.Disclosure: The authors have no interest, financial or oth-erwise that create a conflict with the information presented in this article.ReconstructiveFrom the *Division of Plastic and Reconstructive Surgery, University of Kentucky, Lexington, Ky.; and †Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Ky.Received for publication July 8, 2020; accepted August 29, 2020.Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.DOI: 10.1097/GOX.0000000000003197INTRODUCTIONThe role of plastic surgery in severe cardiovascular infections has a longstanding history, including the use of vascularized tissue transfer for treatment of deep ster-nal wound and device-associated infections after cardiac surgery.1–6 Abscesses of the aortic root are an exceedingly destructive form of infective endocarditis. Antibiotics alone are typically ineffective, and aggressive pathology has been associated with both prosthetic valves and  Staphylococcus aureus infection.7 Surgical management is associated with improved clinical outcomes but has been plagued by high morbidity and mortality.8 After extensive debridement, aortic root reconstruction is performed by patching the remaining tissue and placing an aortic valve prosthesis.9 Unfortunately, a rising incidence of cardiovascular infec-tions has been directly linked to the current opioid epi-demic.10 As the opioid epidemic continues, there is utility in pursuing multidisciplinary care of affected patients.CASE PRESENTATIONWe present our consecutive series of 4 patients who have undergone successful omental flap coverage of severe aortic root abscesses. All patients had a history of intravenous drug abuse and most had undergone prior cardiac valve replacement by our cardiothoracic surgery colleagues, as indicated in Table 1. Due to recurrent intra-venous drug use and chronic endocarditis, each patient ultimately developed a severe aortic root infection and underwent vascularized tissue coverage at the time of aor-tic root reconstruction.CHOICE OF PROCEDURETraditional coverage options for thoracic reconstruc-tion have employed pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps. These flaps offer the advan-tage of tissue bulk, which provides ample coverage in cases of extensive tissue loss. Anatomic considerations preclude the use of pectoralis or rectus flaps after internal mam-mary artery harvest, as is common in many cardiac surgery patients. In each of the aforementioned cases, the desired effect was not expansive tissue coverage, but rather protec-tion of finer structures and antimicrobial defense. In this clinical scenario, the omentum is superior, given its amor-phous structure and immunogenic properties.OMENTAL FLAP TECHNIQUEOur preferred technique begins with a laparotomy incision made in continuity with the patient’s sternotomy Alisha R. Bonaroti, MD*R. Wesley Edmunds, MD*Ryan C. DeCoster, MD, PhD*James Y. Liau, MD, FACS*Michael E. Sekela, MD, FACS†Henry C. Vasconez, MD, FACS* Summary: Aortic root abscesses are severe sequelae of endocarditis that clinically manifest as life-threatening infection. As the opioid epidemic continues to yield a national crisis, the incidence and severity of this disease process have increased. Reconstruction of the aortic root is a challenging undertaking and carries the risk of recurrent infection. The omentum has an established reputation as a reliable flap in thoracic reconstruction, given its amorphous form and immunogenic prop-erties, but it has not been utilized for aortic root infections. We present a novel indication for the omental flap using a cardioplastic approach in coverage of aortic root reconstruction. Four patients were treated with pedicled omental flap cover-age after aortic root reconstruction. All patients had successful flap healing with no evidence of recurrent infection. This series demonstrates the technical feasibility and clinical utility for providing soft tissue coverage and antimicrobial protection when used in aortic root reconstruction. (Plast Reconstr Surg Glob Open 2020;8:e3197; doi: 10.1097/GOX.0000000000003197; Published online 28 October 2020.)Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid EraIdeas and InnovatIonsPRS Global Open • 20202incision. (See Video [online], which displays harvest and transposition of the omental flap for coverage of aortic root reconstruction.) A Balfour retractor is used for ade-quate exposure. We begin by dissecting the omental apron from the transverse colon, as shown in Figure 1 using a Ligasure device or the Harmonic scalpel. We then proceed with ligation of the omentum from the greater curvature of the stomach in a left-to-right fashion. Silk hand ties are used to augment electrocautery when dividing the short gastric arteries. The pedicled flap is based upon the right gastroepiploic artery, as shown in Figure  2, which gen-erally has a bounding pulse. The flap can then be easily rotated into the thoracic defect without tension, as shown in Figure  3. A small retrosternal subxiphoid window is created with electrocautery to allow passage of the omen-tum into the mediastinum. The omental flap is then inset around the aortic root construct using absorbable suture. The anterior abdominal wall and diaphragm are loosely reapproximated over the pedicle. Mediastinal drains are placed by our cardiothoracic surgery colleagues.RESULTSFour patients were treated with immediate pedicled omental flap coverage after aortic root reconstruction. Operative and hospital mortality was 0. All patients had successful flap healing with no evidence of recurrent infection. One patient was readmitted 2 months postop-eratively for increasing heart failure symptoms, which were determined to be secondary to a mechanical issue with the prosthetic valve rather than recurrent infection. This patient underwent reoperation and the field was noted to be free of infection. No patients had complica-tions related to epigastric hernia, incisional hernia, or flap necrosis. Mean hospital length of stay was 36.7 days. Mean length of follow-up was 10.0 months.Table 1. Patient Demographics and Case CharacteristicsPatient 1 2 3 4Age, gender 33, male 44, male 55, male 54, maleCo-morbidities Popliteal artery embolus, AV block, severe AI, CVA, atrial fibrillation, HCV, rhabdomyolysis, brain aneurysm, anxiety, depressionC3–C4 chronic osteomyelitis, endophthalmitis, HCV, hypertension, asthmaMeningitis, renal failure, inguinal hernia repair, forearm fractureAnxiety, hypertension, COPD, tracheostomy, CAD, HCV, seizure, CVAPrior valve replacements2 2 0 1Prior abdominal surgeryNo No No NoBMI 25.5 28.8 19.6 19.7Tobacco use Yes Yes Yes YesIVDU Yes Yes Yes YesPresenting diagnosesAortic root abscess, infected mechanical valve conduit, aortic arch pseudoaneurysmAortic root abscess, infected mechanical valve, splenic and renal emboli, mesenteric massAortic root abscess, left ventricular outflow tract fistula to the right atrium, meningitis, mitral valve vegetationAortic root abscess, cachexia, encephalopathySurgical proceduresRevisional aortic root reconstruction with25 mm Medtronic Freestyle porcine root and 22 mmDacron tube graftAortic root reconstruction with 25 mm Medtronic Freestyle porcine root, biopsy of mesenteric tumorAortic root reconstruction with 27 mm Freestyle porcine root and 24 mm Dacron tube graft, trans left atrial removal of mitral valve vegetation, repair of right atrial fistula and mitral annulus using an acellular xenograft patchRevisional aortic root reconstruction with 27 mm Freestyle porcine root and 26 mm Dacron tube graft, transverse aortic repair of mitral valve using a small acellular xenograft patchOmental flap detailsLigasure device, prevena vac, one 36 French chest tubeHarmonic scalpel, vertical retrosternal window, one 28 French tube, one 36 French tubeHarmonic scalpel, vertical retrosternal window, one 36 French tube, two 28 French tubesLigasure device, splenic bleeding, prevena vac, one 36 French tubeFlap pedicle Right and left gastroepiploicRight gastroepiploic Right gastroepiploic Right gastroepiploicPostoperative courseAKI Ileus, AKI, penicillin desensitizationRespiratory failure, volume overload, neutropenia, readmitted for mechanical issueAtrial fibrillation, aspiration, AKILength of stay (days)29 46 40 32Length of follow-up (months)11.4 10.0 9.8 8.9AI, aortic insufficiency; AKI, acute kidney injury; AV, atrioventricular; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CVA, cerebral vascular accident; HCV, hepatitis C virus. Bonaroti et al. • Omental Flap in Aortic Root Infections3DISCUSSIONAn aortic root abscess is an exceedingly destructive form of infective endocarditis that can manifest as vari-ous types of pathology, including fistula, pseudoaneurysm, coronary obstruction, or arrhythmia.8,9 As the opioid epi-demic has continued to spiral, intravenous drug use undoubtedly plays a role in the incidence and severity of such disease. All cases in this series involved recidivant drug use, with subsequent infection recurrence leading to aortic root infections.Notably, most patients in this series had received at least 1 coronary valve replacement in the past. This does raise significant bioethical issues surrounding the ramifi-cations of recurrent drug use and resource allocation. We suspect that many patients present fairly late due to fac-tors such as poor access and smoldering disease state. As patients are affected by more frequent, severe infections and the indications for cardiac surgery are liberalized, the plastic surgeon will be called upon to assist in improving outcomes.The omental flap is the superior choice for aortic root coverage due to its form and function. The reliable vas-cular pedicle provides mobility and versatility. Puma et al. previously reported the feasibility of laparoscopic omental harvest for coverage of sternal wounds.11 Most notably, the omentum has established immunogenic properties that aid in healing potential.12,13 Regeneration occurs through cellular proliferation, and fibrous tissue growth ultimately creates adhesions to obliterate dead space.14 Associated lymphoid tissue may eradicate infection and clear wound secretions, enhancing the antimicrobial effect. Moreover, the omentum has been shown to deliver angiogenic fac-tors such as vascular endothelial growth factor,15 which confers a significant advantage over muscle flaps. Lastly, the form of the omentum is supple and “amorphous,” which makes it well suited for coverage of deeper, finer structures.16The omental flap is a versatile tool in the reconstruc-tive armamentarium of the plastic surgeon, which was once considered a salvage procedure, but has become increasingly utilized.2 Additional indications include augmentation of high-risk pulmonary or gastrointes-tinal anastomoses, autologous coverage of scalp or extremity defects, and obliteration of dead space in pel-vic reconstruction. The omental flap may soon be an art lost to general or cardiothoracic surgeons. However, an immediate reconstructive approach that involves the plastic surgeon has been shown to decrease mor-bidity and mortality in the treatment of severe cardiac infections.16CONCLUSIONSThe omental flap has classically represented a main-stay for thoracic reconstruction, given its robust vascular Fig. 1. the omental apron is dissected from the transverse colon using the Ligasure device or Harmonic scalpel.Fig. 2. the pedicled flap is based upon the right gastroepiploic artery. the aortic root reconstruction with dacron tube graft is noted superiorly.PRS Global Open • 20204supply, thin pliable form, and immunogenic properties. As severe cardiac infections become increasingly more common in the era of opioid abuse, the indications for reconstructive procedures have become liberalized and a cardioplastic approach is advantageous in improving out-comes. This series demonstrates the technical feasibility and clinical utility of the omental flap, particularly for use in severe aortic root infections.Henry C. Vasconez, MDDivision of Plastic and Reconstructive SurgeryUniversity of Kentucky College of Medicine740 S. Limestone, Lexington, KY 41036E-mail: hcvasc@uky.eduREFERENCES 1. Kaul P. Sternal reconstruction after post-sternotomy mediastini-tis. J Cardiothorac Surg. 2017;12:94.  2. Spindler N, Etz CD, Misfeld M, et al. Omentum flap as a sal-vage procedure in deep sternal wound infection. Ther Clin Risk Manag. 2017;13:1077–1083.  3. Wornom IL III, Maragh H, Pozez A, et al. Use of the omentum in the management of sternal wound infection after cardiac trans-plantation. Plast Reconstr Surg. 1995;95:697–702.  4. Cusimano LA, Wolfe ET, Tan P, et al. Left ventricular assist device salvage with omental flap. Plast Reconstr Surg Glob Open. 2017;5:e1250.  5. Tewarie L, Moza AK, Khattab MA, et al. Effective combination of different surgical strategies for deep sternal wound infection and mediastinitis. Ann Thorac Cardiovasc Surg. 2019;25:102–110.  6. Roussel LO, Khouri JS, Christiano JG. Pedicled flap closure as an adjunct for infected ventricular assist devices. Ann Plast Surg. 2017;78:712–716.  7. Anguera I, Miro JM, Cabell CH, et al; ICE-MD investigators. Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database. Am J Cardiol. 2005;96:976–981.  8. Kirali K, Sarikaya S, Ozen Y, et al. Surgery for aortic root abscess: a 15-year experience. Tex Heart Inst J. 2016;43:20–28.  9. Chen GJ, Lo WC, Tseng HW, et al. Outcome of surgical inter-vention for aortic root abscess: a meta-analysis. Eur J Cardiothorac Surg. 2018;53:807–814.  10. Kadri AN, Wilner B, Hernandez AV, et al. Geographic trends, patient characteristics, and outcomes of infective endocarditis associated with drug abuse in the United States from 2002 to 2016. J Am Heart Assoc. 2019;8:e012969.  11. Puma F, Fedeli C, Ottavi P, et al. Laparoscopic omental flap for the treatment of major sternal wound infection after cardiac sur-gery. J Thorac Cardiovasc Surg. 2003;126:1998–2002.  12. Seguin JR, Loisance DY. Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection. Chest. 1985;88:684–686.  13. Omura K, Misaki T, Takahashi H, et al. Omental transfer for the treatment of sternal infection after cardiac surgery: report of three cases. Surg Today. 1994;24:67–71.  14. Shah S, Sinno S, Vandevender D, et al. Management of thoracic aortic graft infections with the omental flap. Ann Plast Surg. 2013;70:680–683.  15. Eifert S, Kronschnabl S, Kaczmarek I, et al. Omental flap for recurrent deep sternal wound infection and mediastinitis after cardiac surgery. Thorac Cardiovasc Surg. 2007;55:371–374.  16. Frautschi RS, Bassiri Gharb B, Duong MM, et al. The cardioplas-tic approach to the treatment of infected aortic grafts. Ann Plast Surg. 2017;79:221–225. Fig. 3. omental flap inset surrounding aortic root reconstruction.

Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era

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Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era

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