Treatment of septic shock complicated by mediastinitis after HeartMate 3 BiVAD implantation using echo-guided device parameter optimization: a case report

Introduction : Septic shock complicated by poststernotomy mediastinitis in patients with mechanical circulatory support devices is a rare and life-threatening condition associated with high mortality. Management is particularly challenging because of the presence of prosthetic material and the risk of device contamination. Case presentation : We report a 63-year-old man with end-stage nonischemic cardiomyopathy who underwent HeartMate 3 biventricular assist device (BiVAD) implantation as bridge-to-transplant therapy. Four weeks after discharge, he was readmitted with septic shock, multiorgan failure, and mediastinitis. Treatment included broad-spectrum empirical antimicrobial therapy followed by targeted de-escalation, repeated surgical debridement with prolonged vacuum-assisted closure (VAC) therapy, continuous renal replacement therapy, and individualized echocardiography-guided optimization of BiVAD pump parameters to improve systemic perfusion. Device explantation was avoided. During rehabilitation, orthostatic collapse due to posture-dependent preload insufficiency was diagnosed using upright transesophageal echocardiography and resolved through targeted pump flow adjustment. Conclusion : This case demonstrates that severe septic shock and mediastinitis in BiVAD-supported patients can be successfully managed without device removal through multidisciplinary care, antimicrobial stewardship, VAC therapy, and dynamic echocardiography-guided device optimization.