Polymicrobial Multidrug-Resistant Infection and Fatal Bowel Ischemic Perforation After Urgent Heart Transplantation in a VA-ECMO–Bridged Recipient: A Case Report

Yangyang Jia,1,* Yue Zhu,2,* Hongliu Cai2 1Department of Infection Management, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China; 2Department of Critical Care Medicine, the First Afliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yue Zhu, Department of Critical Care Medicine, the First Afliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China, Email [email protected]: Post-transplant infection caused by multidrug-resistant organisms (MDROs) is a major challenge in heart transplantation, especially in recipients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) before surgery. We describe a 52-year-old man with non-ST-elevation myocardial infarction and refractory cardiogenic shock who required VA-ECMO, intra-aortic balloon pump support, continuous renal replacement therapy, and mechanical ventilation before urgent heart transplantation. Before transplantation, he had active pneumonia. Donor respiratory culture grew Acinetobacter baumannii, Pseudomonas aeruginosa, and Staphylococcus aureus, whereas donor blood culture and blood metagenomic next-generation sequencing (mNGS) were negative. After transplantation, serial mNGS and conventional cultures revealed rapidly progressive polymicrobial infection involving Stenotrophomonas maltophilia, Burkholderia multivorans, carbapenem-resistant Acinetobacter baumannii, carbapenem-resistant Klebsiella pneumoniae, and vancomycin-resistant Enterococcus faecium. Antimicrobial therapy was repeatedly adjusted, and VA-ECMO was successfully discontinued on postoperative day 13. However, on postoperative day 16, the patient developed bowel ischemia with gastrointestinal perforation, followed by feculent peritonitis, persistent septic shock, progressive multiorgan dysfunction syndrome, and death on postoperative day 24. This case shows that perioperative infection control in VA-ECMO-bridged urgent heart transplant recipients requires more than broad-spectrum antimicrobial escalation. It requires careful assessment of preoperative infection controllability, interpretation of mNGS in conjunction with culture-based susceptibility testing, and early investigation of occult abdominal ischemia when clinical deterioration is unexplained.Keywords: heart transplantation, VA-ECMO, multidrug-resistant organisms, polymicrobial infection, metagenomic next-generation sequencing, gastrointestinal perforation, bowel ischemia, multiorgan dysfunction syndrome