1
|
Maeda S, Toda K, Shimamura K, Nakamoto K, Igeta M, Sakata Y, Sawa Y, Miyagawa S. Preoperative higher right ventricular stroke work index increases the risk of de novo aortic insufficiency after continuous-flow left ventricular assist device implantation. J Artif Organs 2024; 27:222-229. [PMID: 37468735 DOI: 10.1007/s10047-023-01411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
During continuous-flow left ventricular assist device (CF-LVAD) support, hemodynamic shear stress causes a burden on aortic valve (AV) leaflets, leading to de novo aortic insufficiency (AI). This study investigated the influence of preoperative hemodynamic parameters on de novo AI in CF-LVAD recipients. We reviewed 125 patients who underwent CF-LVAD implantation without concomitant AV surgery between 2005 and 2018. De novo AI was defined as moderate or severe AI in those with none or trivial preoperative AI. During mean 30 ± 16 months of CF-LVAD support, de novo AI-free rate was 86% and 67% at 1 and 2 years, respectively. Multivariable analysis showed that higher right ventricular stroke work index (RVSWI) (hazard ratio, 1.12 /g/m2/beat; 95% confidence interval, 1.00-1.20; p = 0.047) and trivial grade AI (hazard ratio, 2.8; 95% confidence interval, 1.2-6.4; p = 0.020) were independent preoperative risk factors for de novo AI. The longitudinal analysis using generalized mixed effects model showed that higher RVSWI was associated with continuous AV closure after LVAD implantation (Odd ratio, 1.20/g/m2/beat; 95% confidence interval, 1.00-1.43 /g/m2/beat; p = 0.047). Right heart catheterization revealed that preoperative RVSWI was positively correlated with postoperative pump flow index in patients with continuously closed AV (r = 0.44, p = 0.04, n = 22). Preoperative higher RVSWI was a significant risk factor for de novo AI following CF-LVAD implantation. In patients with preserved right ventricular function, postoperative higher pump flow may affect AI development via hemodynamic stress on the AV.
Collapse
Affiliation(s)
- Shusaku Maeda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masataka Igeta
- Department of Biostatistics, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| |
Collapse
|
2
|
Kerai A, Doshi S, Laleker A, Majumdar A. Fungal Foe and Mechanical Hearts: A Retrospective Case Series on Candida auris Bloodstream Infection With Left Ventricular Assist Devices. Open Forum Infect Dis 2024; 11:ofae286. [PMID: 38868314 PMCID: PMC11167671 DOI: 10.1093/ofid/ofae286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
No guidelines currently exist for the management of Candida auris bloodstream infection in patients with left ventricular assist devices (LVADs). We aim to share our management experience through this retrospective case series outlining 15 episodes of C auris candidemia identified in 7 patients over 18 months. The initial source of candidemia was central venous catheter in 5 patients, driveline exit site infection in 1 patient, and possible pump infection in 1 patient. All patients were initially treated with micafungin. Despite susceptibility to micafungin, 4 patients experienced recurrent C auris candidemia. All patients died within 1 year of their first episode of C auris candidemia. Source control is challenging in patients with LVADs, and strict infection prevention measures should be practiced. More studies are needed to evaluate the role of newer antifungal agents, use of combination antifungal regimens, and impact on morbidity in patients with LVADs.
Collapse
Affiliation(s)
- Ajay Kerai
- Department of Internal Medicine and Department of Infectious Disease, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Saumil Doshi
- Department of Internal Medicine and Department of Infectious Disease, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Ashley Laleker
- Department of Internal Medicine and Department of Infectious Disease, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Anjali Majumdar
- Division of Allergy and Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| |
Collapse
|
3
|
Imaoka S, Samura T, Yoshioka D, Kawamura M, Kawamura T, Toda K, Miyagawa S. Clinical Outcomes of Left Ventricular Assist Device Pump Infection. ASAIO J 2023; 69:1056-1064. [PMID: 37549664 DOI: 10.1097/mat.0000000000002031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Abstract
Few studies have focused on the clinical outcomes and risk factors of left ventricular assist device (LVAD) pump infection, and no standard treatment for LVAD pump infection has been established. Therefore, we used a therapeutic flowchart to manage LVAD pump infections. We retrospectively evaluated 220 patients who underwent continuous-flow LVAD implantation between January 2005 and March 2021 at Osaka University, Japan. First, we performed wound debridement, negative-pressure wound therapy, antibiotic treatment, and omental flap transposition. Subsequently, we administered conservative treatment, scheduled implantable LVAD exchange, or emergent removal of the implantable LVAD and exchange for extracorporeal LVAD or percutaneous LVAD (IMPELLA). Pump infections occurred in 32 patients. The survival rates of patients with pump infections during LVAD support were 93%, 74%, and 61% at 180 days, 1 year, and 2 years after LVAD pump infection, respectively. Fifteen patients underwent successful heart transplantation. Bridge-to-bridge surgery, preoperative use of venoarterial extracorporeal membrane oxygenation or percutaneous LVAD, high lactate dehydrogenase levels, and driveline infection were significantly associated with pump infection. Our study reveals that poor preoperative condition and driveline infection were significant risk factors for LVAD pump infection.
Collapse
Affiliation(s)
- Shusuke Imaoka
- From the Departments of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka Fu, Japan
| | - Takaaki Samura
- From the Departments of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka Fu, Japan
| | - Daisuke Yoshioka
- From the Departments of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka Fu, Japan
| | - Masashi Kawamura
- From the Departments of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka Fu, Japan
| | - Takuji Kawamura
- From the Departments of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka Fu, Japan
| | - Koichi Toda
- Department of thoracic and cardiovascular surgery, Dokkyo Medical University Saitama Medical center, Saitama Ken, Japan
| | - Shigeru Miyagawa
- From the Departments of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka Fu, Japan
| |
Collapse
|
4
|
Toda K, Bernhardt AM, Mehra MR. Mechanical circulatory support for adults in Japan: A 10-year perspective. Artif Organs 2023. [PMID: 37140177 DOI: 10.1111/aor.14536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/06/2023] [Accepted: 04/06/2023] [Indexed: 05/05/2023]
Abstract
Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid-term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2-year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long-term LVAD support have become important. Five important topics including hemocompatibility-related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia-Pacific region and beyond.
Collapse
Affiliation(s)
- Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Mandeep R Mehra
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Pérez-de la Sota E, Eixerés-Esteve A, García-Cosio D, Delgado-Jiménez JF. Management of a chronically infected left ventricular assist device with heart transplantation: Two-step simplified approach. J Card Surg 2022; 37:2903-2906. [PMID: 35703424 PMCID: PMC9541361 DOI: 10.1111/jocs.16687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/06/2022] [Accepted: 05/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The surgical approach for the treatment of a left ventricular assist device with severe infection may be controversial. MATERIAL & METHODS We present the case of a patient implanted with a HeartWare™ HVAD as a bridge to transplant and chronic infection of the device by Pseudomonas who underwent a conservative partial treatment of the driveline tunnel and subsequently a heart transplantation and device removal were done. CONCLUSIONS The two-step simplified approach allowed the patient to be transplanted in a short period of time, with the abdominal wall healed and almost two-thirds of the driveline subcutaneous tunnel sterilized.
Collapse
Affiliation(s)
- Enrique Pérez-de la Sota
- Cardiac Surgery Department, 12 de Octubre University Hospital, Avenida de Córdoba s/n, Madrid, Spain
| | - Andrea Eixerés-Esteve
- Cardiac Surgery Department, 12 de Octubre University Hospital, Avenida de Córdoba s/n, Madrid, Spain
| | - Dolores García-Cosio
- Cardiology Department, 12 de Octubre University Hospital, Avenida de Córdoba s/n, Madrid, Spain
| | - Juan F Delgado-Jiménez
- Cardiology Department, 12 de Octubre University Hospital, Avenida de Córdoba s/n, Madrid, Spain
| |
Collapse
|
6
|
Chen JW, Heng-Wen C, Chou NK, Wang CH, Chi NH, Huang SC, Yu HY, Chen YS, Hsu RB. Impact of pretransplant bloodstream infection on clinical outcomes after heart transplantation. Transpl Infect Dis 2022; 24:e13834. [PMID: 35427436 DOI: 10.1111/tid.13834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/28/2022] [Accepted: 03/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Active bloodstream infection (BSI) is a contraindication for heart transplantation (HT). However, some critical patients with BSI may undergo HT as a life-saving procedure. We aimed to investigate the impact of pretransplant BSI on the clinical outcomes after HT. METHODS We enrolled 511 consecutive patients who underwent HT between 1999 and 2019. Patients were divided into two groups based on the presence of BSI within 30 days preoperatively. Forty-three patients (8.4%) with BSI who were clinically stable and had no metastatic infection were considered for HT on an individual basis. In-hospital mortality, incidence of early postoperative BSI, length of postoperative hospital stays, and long-term survival were compared between the groups. Logistic and Cox regression analyses were performed to identify risk factors for in-hospital and 1-year mortality. RESULTS Patients with pretransplant BSI had a high incidence of previous cardiopulmonary resuscitation, pretransplant ventilator use, mechanical circulatory support use, renal replacement therapy, United Network for Organ Sharing status 1A, and a prolonged preoperative hospital waiting period. The in-hospital mortality rate was higher in patients with pretransplant BSI (21% versus 12%, p = 0.081), and the mortality rate was very high (33.3%) for those with BSI 0-15 days before HT. In addition, patients with pretransplant BSI had a significantly longer postoperative hospital stay than patients in the control group. However, long-term survival was similar in both groups. CONCLUSIONS Although pretransplant BSI was associated with higher in-hospital mortality and prolonged postoperative hospital stay, patients who survived the early period had a similar long-term prognosis. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chou Heng-Wen
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nai-Kuan Chou
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Nai-Hsin Chi
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsi-Yu Yu
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ron-Bin Hsu
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
7
|
Ono M, Yamaguchi O, Ohtani T, Kinugawa K, Saiki Y, Sawa Y, Shiose A, Tsutsui H, Fukushima N, Matsumiya G, Yanase M, Yamazaki K, Yamamoto K, Akiyama M, Imamura T, Iwasaki K, Endo M, Ohnishi Y, Okumura T, Kashiwa K, Kinoshita O, Kubota K, Seguchi O, Toda K, Nishioka H, Nishinaka T, Nishimura T, Hashimoto T, Hatano M, Higashi H, Higo T, Fujino T, Hori Y, Miyoshi T, Yamanaka M, Ohno T, Kimura T, Kyo S, Sakata Y, Nakatani T. JCS/JSCVS/JATS/JSVS 2021 Guideline on Implantable Left Ventricular Assist Device for Patients With Advanced Heart Failure. Circ J 2022; 86:1024-1058. [PMID: 35387921 DOI: 10.1253/circj.cj-21-0880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Akira Shiose
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Kenji Yamazaki
- Advanced Medical Research Institute, Hokkaido Cardiovascular Hospital
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Teruhiko Imamura
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama
| | - Kiyotaka Iwasaki
- Cooperative Major in Advanced Biomedical Sciences, Graduate School of Advanced Science and Engineering, Waseda University
| | - Miyoko Endo
- Department of Nursing, The University of Tokyo Hospital
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Koichi Kashiwa
- Department of Medical Engineering, The University of Tokyo Hospital
| | - Osamu Kinoshita
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Kaori Kubota
- Department of Transplantation Medicine, Osaka University Graduate School of Medicine
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroshi Nishioka
- Department of Clinical Engineering, National Cerebral and Cardiovascular Center
| | - Tomohiro Nishinaka
- Department of Artificial Organs, National Cerebral and Cardiovascular Center
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Hospital
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Masaru Hatano
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Takeo Fujino
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Yumiko Hori
- Department of Nursing and Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | | | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | | |
Collapse
|
8
|
Akil A, Rehers S, Köhler C, Richter L, Semik M, Ziegeler S, Fischer S. Multidisciplinary management of pleural infection after ventricular assist device implantation. J Thorac Dis 2021; 13:4661-4667. [PMID: 34527307 PMCID: PMC8411140 DOI: 10.21037/jtd-20-2886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/21/2021] [Indexed: 11/06/2022]
Abstract
Background Postsurgical pleural infection is a life-threatening complication after implantation of artificial devices such as ventricular assist devices (VADs). The treatment can be challenging and the evidence in the literature is very limited. Here we report our multidisciplinary approach of the management of pleural infection after VAD implantation. Methods Between March 2014 and December 2019, 33 patients developed postoperative pleural infection after VAD implantation and underwent thoracic surgical intervention at our institution. All patients were prospectively enrolled in this analysis. Data were retrospectively analyzed. Primary outcome was the 90-day mortality rate. Length of ICU stay related to pleural infection, chest tube duration, re-thoracotomy rate and length of ventilatory support represented secondary outcomes. Results The 90-day mortality rate was 6% (2 patients). The mean ICU stay related to the pleural infection was 6 days (2-24 days). Video-assisted thoracoscopic surgery (VATS) was performed in all patients. Conversion to thoracotomy was necessary in 12 cases. Decortication and parietal pleurectomy in addition to hematoma and empyema removal was performed in all patients. Due to diffuse bleeding, packing of the thoracic cavity with temporary thoracic closure was necessary in 10 patients. Depacking was performed after a mean of 3 days (3-7 days). Recurrent empyema or bleeding after definitive chest closure was not observed. Lung resection was performed in 3 patients. Conclusions Thoracic surgical management of pleural infection in patients after VAD implantation is challenging and complicated due to the inevitable anticoagulative therapy. A perioperative multidisciplinary management which includes the early involvement of thoracic surgical expertise helps to improve survival in this very complex patient cohort.
Collapse
Affiliation(s)
- Ali Akil
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Stephanie Rehers
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Christian Köhler
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Lars Richter
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Michael Semik
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Stephan Ziegeler
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| |
Collapse
|
9
|
Cho SM, Tahsili-Fahadan P, Kilic A, Choi CW, Starling RC, Uchino K. A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke. Semin Neurol 2021; 41:411-421. [PMID: 33851393 DOI: 10.1055/s-0041-1726328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.
Collapse
Affiliation(s)
- Sung-Min Cho
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pouya Tahsili-Fahadan
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Neuroscience Intensive Care Unit, Department of Medicine, Virginia Commonwealth University, Inova Fairfax Medical Campus, Falls Church, Virginia.,Neuroscience Research, Neuroscience and Spine Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ahmet Kilic
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun Woo Choi
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ken Uchino
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW The use of durable ventricular assist devices (VAD) to manage end-stage heart failure is increasing, but infection remains a leading cause of morbidity and mortality among patients with VAD. In this review, we synthesize recent data pertaining to the epidemiology, diagnosis, management, and prevention of VAD infections, discuss transplant considerations in patients with VAD infections, and highlight remaining knowledge gaps. We also present a conceptual framework for treating clinicians to approach these infections that draws on the same principles that guide the treatment of analogous infections that occur in patients without VAD. RECENT FINDINGS Despite advances in device design, surgical techniques, and preventative interventions, more than a third of VAD recipients still experience infection as an adverse outcome. Positron emission tomography has emerged as a promising modality for identifying and characterizing VAD infections. High-quality data to support many of the routine therapeutic strategies currently used for VAD infections-including suppressive antibiotic therapy, surgical debridement/device exchange, and novel antimicrobials for emerging multidrug-resistant organisms-remain limited. Although pre-transplant VAD infection may impact some early transplant outcomes, transplantation remains a viable option for patients with most types of VAD infection. Standardized definitions of VAD infection applied to large registry datasets have yielded key insights into the epidemiology of infectious complications among VAD recipients, but more prospective studies are needed to evaluate the effectiveness of existing and novel diagnostic and therapeutic strategies.
Collapse
Affiliation(s)
- Varun K Phadke
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.
| | - Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
11
|
Blanco-Guzman MO, Wang X, Vader JM, Olsen MA, Dubberke ER. Epidemiology of Left Ventricular Assist Device Infections: Findings From a Large Nonregistry Cohort. Clin Infect Dis 2021; 72:190-197. [PMID: 31925953 PMCID: PMC7982342 DOI: 10.1093/cid/ciaa011] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/10/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Infection is a major complication during circulatory support with a left ventricular assist device (VAD). Changes in device characteristics and treatment practices in the last decade can affect the epidemiology of infection. The International Society for Heart and Lung Transplantation (ISHLT) has published recommendations on the prevention and management of VAD infections, but data to support these recommendations remain sparse. METHODS We performed a retrospective review of 455 patients who underwent VAD placement from 2009 to 2015. Infection episodes were defined using ISHLT criteria and were also grouped as endovascular or local. Analysis included descriptive statistics. RESULTS There were 174 patients (38.6%) with a VAD infection. Infection incidence was 36.9 cases per 100 person-years of VAD support. The driveline was the most common infection site (67.2%). Systemic inflammatory response syndrome (SIRS) criteria were not satisfied in 29.2% of patients with endovascular infections, and computed tomography (CT) examinations were normal in 37.7% of cases. Gram-positive bacteria caused 65.6% of infections in patients with an available culture. Antimicrobial suppression was used in 72.3% of patients who survived treatment. Median survival after infection was 35 months for patients with VAD-related infections versus 14 months for patients with VAD-specific infections. CONCLUSIONS VAD infections continue to be a major complication after implantation. Clinical criteria alone were not predictive of serious infections, and many patients with confirmed infection had normal CTs. Patients with VAD-specific infections had lower median survival than patients with VAD-related infections.
Collapse
Affiliation(s)
- Merilda O Blanco-Guzman
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | - Xiaowen Wang
- Division of Medical Education, Washington University School of Medicine, St Louis, Missouri, USA
| | - Justin M Vader
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Margaret A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
12
|
Ventricular Assist Device-Specific Infections. J Clin Med 2021; 10:jcm10030453. [PMID: 33503891 PMCID: PMC7866069 DOI: 10.3390/jcm10030453] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 12/30/2022] Open
Abstract
Ventricular assist device (VAD)-specific infections, in particular, driveline infections, are a concerning complication of VAD implantation that often results in significant morbidity and even mortality. The presence of a percutaneous driveline at the skin exit-site and in the subcutaneous tunnel allows biofilm formation and migration by many bacterial and fungal pathogens. Biofilm formation is an important microbial strategy, providing a shield against antimicrobial treatment and human immune responses; biofilm migration facilitates the extension of infection to deeper tissues such as the pump pocket and the bloodstream. Despite the introduction of multiple preventative strategies, driveline infections still occur with a high prevalence of ~10-20% per year and their treatment outcomes are frequently unsatisfactory. Clinical diagnosis, prevention and management of driveline infections are being targeted to specific microbial pathogens grown as biofilms at the driveline exit-site or in the driveline tunnel. The purpose of this review is to improve the understanding of VAD-specific infections, from basic "bench" knowledge to clinical "bedside" experience, with a specific focus on the role of biofilms in driveline infections.
Collapse
|
13
|
Immohr MB, Boeken U, Mueller F, Prashovikj E, Morshuis M, Böttger C, Aubin H, Gummert J, Akhyari P, Lichtenberg A, Schramm R. Complications of left ventricular assist devices causing high urgency status on waiting list: impact on outcome after heart transplantation. ESC Heart Fail 2021; 8:1253-1262. [PMID: 33480186 PMCID: PMC8006689 DOI: 10.1002/ehf2.13188] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/19/2020] [Accepted: 12/11/2020] [Indexed: 01/10/2023] Open
Abstract
Aims Heart transplantation (HTx) represents optimal care for advanced heart failure. Left ventricular assist devices (LVADs) are often needed as a bridge‐to‐transplant (BTT) therapy to support patients during the wait for a donor organ. Prolonged support increases the risk for LVAD complications that may affect the outcome after HTx. Methods and results A total of 342 patients undergoing HTx after LVAD as BTT in a 10‐year period in two German high‐volume HTx centres were retrospectively analysed. While 73 patients were transplanted without LVAD complications and with regular waiting list status (T, n = 73), the remaining 269 patients were transplanted with high urgency status (HU) and further divided with regard to the observed leading LVAD complications (infection: HU1, n = 91; thrombosis: HU2, n = 32; stroke: HU3, n = 38; right heart failure: HU4, n = 41; arrhythmia: HU5, n = 23; bleeding: HU6, n = 18; device malfunction: HU7, n = 26). Postoperative hospitalization was prolonged in patients with LVAD complications. Analyses of perioperative morbidity revealed no differences regarding primary graft dysfunction, renal failure, and neurological events except postoperative infections. Short‐term survival, as well as Kaplan–Meier survival analysis, indicated comparable results between the different study groups without disadvantages for patients with LVAD complications. Conclusions Left ventricular assist device therapy can impair the outcome after HTx. However, the occurrence of LVAD complications may not impact on outcome after HTx. Thus, we cannot support the prioritization or discrimination of HTx candidates according to distinct mechanical circulatory support‐associated complications. Future allocation strategies have to respect that device‐related complications may define urgency but do not impact on the outcome after HTx.
Collapse
Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Franziska Mueller
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Emir Prashovikj
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Charlotte Böttger
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - René Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| |
Collapse
|
14
|
The Impact of Left Ventricular Assist Device Infections on Postcardiac Transplant Outcomes: A Systematic Review and Meta-Analysis. ASAIO J 2020; 65:827-836. [PMID: 30575630 DOI: 10.1097/mat.0000000000000921] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Left ventricular assist devices (LVADs) are associated with numerous short- and long-term complications, including infection. The impact LVAD infections have on clinical outcomes after transplantation is not well established. We sought to determine whether the presence of infection while on LVAD support negatively influences outcomes after cardiac transplantation. We searched electronic databases and bibliographies for full text studies that identified LVAD infections during support and also reported on posttransplant outcomes. A meta-analysis of posttransplant survival was conducted using a random effects model. Of 2,373 records, 13 bridge to transplant (BTT) cohort studies were selected (n = 6,631, 82% male, mean age 50.7 ± 2.7 years). A total of 6,067 records (91.5%) received transplant. There were 3,718 (56.1%) continuous-flow LVADs (CF-LVADs), 1,752 (26.4%) pulsatile LVADs, and 1,161 (17.5%) unknown type records. A total of 2,586 records (39.0%) developed LVAD infections. Patients with LVAD infections were younger (50.5 ± 1.5 vs. 51.3 ± 1.5, p = 0.02), had higher body mass indeices (BMIs) (28.4 ± 0.7 vs. 26.8 ± 0.4, p < 0.01), and longer LVAD support times (347.0 ± 157.6 days vs. 180.2 ± 106.0 days, p < 0.01). Meta-analysis demonstrated increased posttransplant mortality in those patients who had an LVAD infection (hazard ratio [HR] 1.30, 95% CI: 1.16-1.46, p < 0.001). Subgroup meta-analyses by continuous-flow and pulsatile device type demonstrated significant increased risk of death for both types of devices (HR 1.47, 95% CI: 1.22-1.76, p < 0.001 and 1.71, 95% CI: 1.19-2.45, p = 0.004, respectively). Patients who develop LVAD infections are younger, have higher BMIs and longer LVAD support times. Our data suggests that LVAD-related infections result in a 30% increase in postcardiac transplantation mortality. Strategies to prevent LVAD infections should be implemented to improve posttransplant outcomes in this high-risk population.
Collapse
|
15
|
Bloodstream Infections in Continuous Flow Left Ventricular Assist Device Recipients: Diagnostic and Clinical Implications. ASAIO J 2020; 65:798-805. [PMID: 30234503 DOI: 10.1097/mat.0000000000000881] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Bloodstream infection (BSI) is a common complication of left ventricular assist device (LVAD) support and particularly difficult to treat. The presentation is often variable because of altered physiology and augmentation of cardiac output by the device. We studied LVAD recipients at a single institution. Multivariate logistic and Cox (with time-varying parameters) regression were implemented. Of 212 patients, 58% experienced infections. Driveline infection (DLI) affected 31%, with 60% of them having deep-tissue involvement. Sixty-six patients (31%) suffered from 135 BSIs. Systemic inflammatory response syndrome (SIRS) was present in 47% of BSIs at presentation and associated with increased mortality. Right heart failure, destination therapy, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, morbid obesity, and deep-DLI were independent risk factors for BSI. The BSI was independently associated with mortality. Bridge-to-transplantation (BTT) patients were more likely to receive transplant if they did not have BSIs. Among 104 BTT patients who received heart transplantation, development of BSI was associated with shorter time-to-transplantation. Diagnosis of BSI poses diagnostic and prognostic challenges because of the hemodynamic profile of LVAD patients who may not mount the expected physiologic response to sepsis. Although SIRS criteria lack sensitivity in the LVAD population, SIRS signifies increased risk for death. Deep DLI was the strongest predictor of BSI. Despite the upgrade in listing status of BTT-LVADs with BSIs and shorter time-to-transplantation, BSI remain a major cause of mortality. BSIs are associated with significant mortality and should be regarded as a serious complication, similar to pump thrombosis and stroke.
Collapse
|
16
|
Angleitner P, Matic A, Kaider A, Dimitrov K, Sandner S, Wiedemann D, Riebandt J, Schlöglhofer T, Laufer G, Zimpfer D. Blood stream infection and outcomes in recipients of a left ventricular assist device. Eur J Cardiothorac Surg 2020; 58:907-914. [DOI: 10.1093/ejcts/ezaa153] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 01/18/2023] Open
Abstract
Abstract
OBJECTIVES
Our aim was to investigate associations between blood stream infection [≥1 positive blood culture (BC)] and outcomes in recipients of a left ventricular assist device (LVAD).
METHODS
We retrospectively analysed all adult recipients of a continuous-flow LVAD between 2006 and 2016 at the Division of Cardiac Surgery, Medical University of Vienna (n = 257; devices: Medtronic HeartWare® HVAD®, Abbott HeartMate II®, Abbott HeartMate 3™). The primary outcome was all-cause mortality during follow-up. Secondary outcomes included the risk of stroke and pump thrombus during follow-up as well as the probability of heart transplantation (HTx). Risk factors for the development of ≥1 positive BC were evaluated additionally.
RESULTS
The incidence of ≥1 positive BC during the first year of LVAD support was 32.1% [95% confidence interval (CI) 26.4–37.9]. Multivariable Cox proportional cause-specific hazards regression analysis showed that a positive BC was associated with significantly increased all-cause mortality [hazard ratio (HR) 5.51, 95% CI 3.57–8.51; P < 0.001]. Moreover, a positive BC was associated with a significantly increased risk of stroke (HR 2.41, 95% CI 1.24–4.68; P = 0.010). There was no association with the risk of pump thrombus or the probability of HTx. Independent risk factors for a positive BC included preoperative albumin and extracorporeal membrane oxygenation/intra-aortic balloon pump support.
CONCLUSIONS
Blood stream infection is common and associated with a significantly increased risk of all-cause mortality and stroke at any given time during LVAD support. Effective strategies of prevention and treatment are necessary.
Collapse
Affiliation(s)
- Philipp Angleitner
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Aleksa Matic
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics, and Intelligent Systems (CEMSIIS), Medical University of Vienna, Vienna, Austria
| | - Kamen Dimitrov
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Sigrid Sandner
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
17
|
Expanding Use of New Technology Creates New Challenges in Preventing and Managing Infections: a Review of Diagnostic and Management Considerations for Infections Among Patients with Long-Term Invasive Devices for Advanced Heart Failure. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00724-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
18
|
Zinoviev R, Lippincott CK, Keller SC, Gilotra NA. In Full Flow: Left Ventricular Assist Device Infections in the Modern Era. Open Forum Infect Dis 2020; 7:ofaa124. [PMID: 32405511 PMCID: PMC7209633 DOI: 10.1093/ofid/ofaa124] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
With the rising prevalence of heart disease in the United States, there is increasing reliance on durable mechanical circulatory support (MCS) to treat patients with end-stage heart failure. Left ventricular assist devices (LVADs), the most common form of durable MCS, are implanted mechanical pumps that connect to an external power source through a transcutaneous driveline. First-generation LVADs were bulky, pulsatile pumps that were frequently complicated by infection. Second-generation LVADs have an improved design, though infection remains a common and serious complication due to the inherent nature of implanted MCS. Infections can affect any component of the LVAD, with driveline infections being the most common. LVAD infections carry significant morbidity and mortality for LVAD patients. Therefore, it is paramount for the multidisciplinary team of clinicians caring for these patients to be familiar with this complication. We review the epidemiology, prevention, diagnosis, treatment, and outcomes of LVAD infections.
Collapse
Affiliation(s)
- Radoslav Zinoviev
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher K Lippincott
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sara C Keller
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Department of Medicine - Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
19
|
Movahedi F, Kormos RL, Lohmueller L, Seese L, Kanwar M, Murali S, Zhang Y, Padman R, Antaki JF. Sequential Pattern Mining of Longitudinal Adverse Events After Left Ventricular Assist Device Implant. IEEE J Biomed Health Inform 2019; 24:2347-2358. [PMID: 31831453 DOI: 10.1109/jbhi.2019.2958714] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Left ventricular assist devices (LVADs) are an increasingly common therapy for patients with advanced heart failure. However, implantation of the LVAD increases the risk of stroke, infection, bleeding, and other serious adverse events (AEs). Most post-LVAD AEs studies have focused on individual AEs in isolation, neglecting the possible interrelation, or causality between AEs. This study is the first to conduct an exploratory analysis to discover common sequential chains of AEs following LVAD implantation that are correlated with important clinical outcomes. This analysis was derived from 58,575 recorded AEs for 13,192 patients in International Registry for Mechanical Circulatory Support (INTERMACS) who received a continuous-flow LVAD between 2006 and 2015. The pattern mining procedure involved three main steps: (1) creating a bank of AE sequences by converting the AEs for each patient into a single, chronologically sequenced record, (2) grouping patients with similar AE sequences using hierarchical clustering, and (3) extracting temporal chains of AEs for each group of patients using Markov modeling. The mined results indicate the existence of seven groups of sequential chains of AEs, characterized by common types of AEs that occurred in a unique order. The groups were identified as: GRP1: Recurrent bleeding, GRP2: Trajectory of device malfunction & explant, GRP3: Infection, GRP4: Trajectories to transplant, GRP5: Cardiac arrhythmia, GRP6: Trajectory of neurological dysfunction & death, and GRP7: Trajectory of respiratory failure, renal dysfunction & death. These patterns of sequential post-LVAD AEs disclose potential interdependence between AEs and may aid prediction, and prevention, of subsequent AEs in future studies.
Collapse
|
20
|
Koval CE, Stosor V. Ventricular assist device-related infections and solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13552. [PMID: 30924952 DOI: 10.1111/ctr.13552] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 01/06/2023]
Abstract
The Infectious Diseases Community of Practice of the American Society of Transplantation has published evidenced-based guidelines on the prevention and management of infectious complications in SOT recipients since 2004. This updated guideline reviews the epidemiology of ventricular assist device (VAD) infections and provides recommendations for the management and prevention of these infections. Almost one half of those awaiting heart transplantation are supported with VADs. Despite advances in device technologies, VAD infections commonly complicate mechanical circulatory support and remain typified by common components and anatomic locations. These infections have important implications for transplant candidates, most notably increased wait-list mortality. Strategic management of these infections is crucial for successful transplantation. Coincidentally, explantation of all VAD components at the time of transplantation is often the definitive cure for the device-associated infection. Highlighted in this updated guideline is the reported success of transplantation in patients with a variety of pre-existing VAD infections and guidance on post-transplant management strategies.
Collapse
Affiliation(s)
- Christine E Koval
- Department of Infectious Diseases, Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.,Transplant Infectious Diseases, Transplant Center, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Valentina Stosor
- Medicine and Surgery, Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | |
Collapse
|
21
|
FDG PET/CT for Early Detection and Localization of Left Ventricular Assist Device Infection. JACC Cardiovasc Imaging 2019; 12:722-729. [DOI: 10.1016/j.jcmg.2018.01.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/11/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
|
22
|
Legallois D, Manrique A. Diagnosis of infection in patients with left ventricular assist device: PET or SPECT? J Nucl Cardiol 2019; 26:56-58. [PMID: 29948891 DOI: 10.1007/s12350-018-1324-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/04/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Damien Legallois
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, 14000, Caen, France.
- Department of Cardiology, CHU de Caen, 14000, Caen, France.
| | - Alain Manrique
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, 14000, Caen, France
- Department of Nuclear Medicine, CHU de Caen, 14000, Caen, France
- GIP Cyceron PET Center, Investigations chez l'Homme, Campus Jules Horowitz, BP 5229, 14074, Caen, France
| |
Collapse
|
23
|
Wrobel CA, Drazner MH, Ayers CR, Pham DD, La Hoz RM, Grodin JL, Garg S, Mammen PPA, Morlend RM, Araj F, Amin AA, Cornwell WK, Thibodeau JT. Delayed febrile response with bloodstream infections in patients with continuous-flow left ventricular assist devices. J Investig Med 2019; 67:653-658. [PMID: 30696751 DOI: 10.1136/jim-2018-000893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2018] [Indexed: 11/03/2022]
Abstract
Bloodstream infections (BSIs) are common in patients with continuous-flow left ventricular assist devices (CF-LVADs). Whether CF-LVADs modulate the febrile response to BSIs is unknown. We retrospectively compared the febrile response to BSIs in patients with heart failure (HF) with CF-LVADs versus a control population of patients with HF receiving inotropic infusions. BSIs were adjudicated using the Centers for Disease Control and Prevention and the National Healthcare Safety Network criteria. Febrile status (temperature ≥38°C, 100.4 °F), temperature at presentation with BSI, and the highest temperature within 72 hours (Tmax) were collected. We observed 59 BSIs in LVAD patients and 45 BSIs in controls. LVAD patients were more likely to be afebrile and to have a lower temperature at presentation than control (88% vs 58%, p=0.002, and 37°C ±0.7 vs 37.7°C ±1.0, p=0.0009, respectively). By 72 hours, the difference in afebrile status diminished (53% vs 44%, p=0.42), and the Tmax was similar between the LVAD and control groups (37.9°C±0.9 vs 38.2°C±0.8, respectively, p=0.10). In conclusion, at presentation with a BSI, the vast majority of CF-LVAD patients were afebrile, an event which occurred at a higher frequency when compared with patients with advanced HF on chronic inotropes via an indwelling venous catheter. These data alert clinicians to have a very low threshold to obtain blood cultures in CF-LVAD patients even in the absence of fever. Further study is needed to determine whether a delayed or diminished febrile response represents another pathophysiological consequence of CF-LVADs.
Collapse
Affiliation(s)
- Christopher A Wrobel
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark H Drazner
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Colby R Ayers
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David D Pham
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ricardo M La Hoz
- Department of Internal Medicine, Division of Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Justin L Grodin
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sonia Garg
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Pradeep P A Mammen
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Robert M Morlend
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Faris Araj
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alpesh A Amin
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William K Cornwell
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jennifer T Thibodeau
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
24
|
Eickmeyer SM, Barker KD, Sayyad A, Rydberg L. The Rehabilitation of Patients With Advanced Heart Failure After Left Ventricular Assist Device Placement: A Narrative Review. PM R 2019; 11:64-75. [PMID: 29929019 DOI: 10.1016/j.pmrj.2018.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/17/2018] [Indexed: 01/18/2023]
Abstract
Because more patients with advanced heart failure are receiving a left ventricular assist device (LVAD) as destination therapy or a bridge to transplantation, there is increasing attention on functional outcomes and quality of life after LVAD implantation. Rehabilitation providers in the acute inpatient rehabilitation setting increasingly will treat patients with an LVAD and should understand the exercise physiology, medical management, rehabilitation considerations, and outcomes after rehabilitation for patients with an LVAD. The purpose of this article is to provide the physiatrist with a comprehensive understanding of the rehabilitation of patients with advanced heart failure and LVAD implantation. Changes in relevant organ system physiology and exercise physiology after LVAD are summarized. Safety of rehabilitation and program considerations for acute inpatient rehabilitation are reviewed. Recommendations for medical management and prevention of secondary complications seen in patients with an LVAD are outlined. A discussion of outcomes after acute inpatient rehabilitation, the dual diagnosis of stroke and LVAD placement, and long-term cognitive, functional, and quality-of-life outcomes after LVAD placement is presented.
Collapse
Affiliation(s)
- Sarah M Eickmeyer
- Department of Rehabilitation Medicine, University of Kansase-Kansas City, 3901 Rainbow Blvd, Kansas City, KS 66160
| | - Kim D Barker
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anjum Sayyad
- Department of Physical Medicine and Rehabilitation, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois; Marianjoy Rehabilitation Hospital, Wheaton, Illinois
| | - Leslie Rydberg
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Shirley Ryan AbilityLab, Chicago, Illinois
| |
Collapse
|
25
|
|
26
|
Abstract
This article reviews the diagnostic criteria for ventricular assist device (VAD) infection, pathogenesis, and microbiology as well as the diagnostic pathway when patients present with signs and symptoms concerning for VAD infection. Recommendations regarding infection prevention and management are reviewed as well.
Collapse
Affiliation(s)
- Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, 4510 Executive Drive, Suite P-725, MC 7745, San Diego, CA 92121, USA.
| |
Collapse
|
27
|
Staphylococcus aureus bloodstream infection in patients with ventricular assist devices-Management and outcome in a prospective bicenter cohort. J Infect 2018; 77:30-37. [PMID: 29778631 DOI: 10.1016/j.jinf.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/10/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Ventricular assist devices (VAD) are increasingly implanted in patients with terminal heart failure. Here we describe the clinical course, management and outcome of VAD patients with S. aureus bloodstream infection (SAB). METHODS We conducted a post hoc analysis of data from 1073 patients who had been prospectively enrolled in two consecutive SAB bicenter cohort studies. Patients with VAD in situ at the onset of SAB were identified. Follow-up of patients was at least 90 days. RESULTS Twelve VAD patients with SAB were identified. Compared to the overall cohort, patients with VAD presented more often with fever (92% vs. 65%) and septic shock (33% vs. 23%) and showed higher C-reactive protein levels (mean 244 vs. 132 g/ml). The median time to onset of SAB after device implantation was 161 days (range 24-790 days). 30-day mortality was comparable to the whole cohort (17% vs. 19%). Infection-related surgical interventions were performed in six patients. Hematogenous dissemination to distant foci was not found in any patient. One out of nine surviving patients required continuous suppressive antibiotic therapy. CONCLUSIONS Mortality rates for VAD patients with SAB were comparable to SAB without VAD. No hematogenous disssemination or persistent infections were recorded, which might be associated with the prompt and aggressive antibiotic and surgical management in VAD patients. SAB per se does not preclude successful transplantation.
Collapse
|
28
|
Blood stream infection is associated with cerebrovascular accident in patients with left ventricular assist device: a systematic review and meta-analysis. J Artif Organs 2018; 21:271-277. [DOI: 10.1007/s10047-018-1034-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 03/12/2018] [Indexed: 01/28/2023]
|
29
|
Abe R, Shibata SC, Saito S, Tsukamoto Y, Toda K, Uchiyama A, Sakata Y, Sawa Y, Tomono K, Fujino Y. Factors Related to the Severity of Early Postoperative Infection After Heart Transplantation in Patients Surviving Prolonged Mechanical Support Periods: Experience at a Single University. J Cardiothorac Vasc Anesth 2018; 32:53-59. [DOI: 10.1053/j.jvca.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Indexed: 11/11/2022]
|
30
|
Sullivan T, Taimur S, Rana M, Patel G, Pinney S, Anyanwu A, Huprikar S. Successful heart transplantation in patients with active Staphylococcus bloodstream infection and suspected mechanical circulatory support device infection. Transpl Infect Dis 2017; 20. [PMID: 29139180 DOI: 10.1111/tid.12812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/18/2017] [Accepted: 08/07/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND An active bloodstream infection (BSI) is typically considered a contraindication to heart transplantation (HT). However, in some patients with Staphylococcus bacteremia and mechanical circulatory support device infection, positive blood cultures may persist until removal of the infected device, and eradicating the infection prior to HT may not be possible. We report the outcomes of six patients with active Staphylococcus BSI at the time of HT. METHODS All cases of HT performed at The Mount Sinai Hospital from 2009 through 2015 were reviewed. All patients with a mechanical circulatory support device and an active Staphylococcus BSI at the time of HT were included. RESULTS Six patients with active Staphylococcus bacteremia and suspected mechanical circulatory support device infection underwent HT. All patients were bacteremic with Staphylococcus species at the time of HT. All were managed with antimicrobial therapy, radical debridement at the time of HT, and limited use of immunosuppression, and all survived until hospital discharge with no evidence of relapsed Staphylococcus infection. CONCLUSION These results suggest that some carefully selected patients with active Staphylococcus bacteremia and suspected mechanical circulatory support device infection may safely undergo HT, and that HT may effectively eliminate the underlying infection.
Collapse
Affiliation(s)
- Timothy Sullivan
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Taimur
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meenakshi Rana
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gopi Patel
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sean Pinney
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anelechi Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shirish Huprikar
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
31
|
An ISHLT consensus document for prevention and management strategies for mechanical circulatory support infection. J Heart Lung Transplant 2017; 36:1137-1153. [DOI: 10.1016/j.healun.2017.06.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022] Open
|
32
|
Pinney SP, Anyanwu AC, Lala A, Teuteberg JJ, Uriel N, Mehra MR. Left Ventricular Assist Devices for Lifelong Support. J Am Coll Cardiol 2017; 69:2845-2861. [PMID: 28595702 DOI: 10.1016/j.jacc.2017.04.031] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 03/23/2017] [Accepted: 04/11/2017] [Indexed: 12/21/2022]
Abstract
Continuous-flow left ventricular assist devices (LVADs) have revolutionized advanced heart failure care. These compact, fully implantable heart pumps are capable of providing meaningful increases in survival, functional capacity, and quality of life. Implantation volumes continue to grow, but several challenges remain to be overcome before LVADs will be considered as the therapy of choice for all patients with advanced heart failure. They must be able to consistently extend survival for the long term (7 to 10 years), rather than the midterm (3 to 5 years) more typical of contemporary devices; they must incorporate design elements that reduce shear stress and avoid stasis to reduce the frequent adverse events of bleeding, stroke, and pump thrombosis; and they must become more cost-effective. The advancements in engineering, implantation technique, and medical management detailed in this review will highlight the progress made toward achieving lifelong LVAD support and the challenges that remain.
Collapse
Affiliation(s)
- Sean P Pinney
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Anelechi C Anyanwu
- Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anuradha Lala
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffrey J Teuteberg
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nir Uriel
- Department of Medicine, Cardiology Division, University of Chicago, Chicago, Illinois
| | - Mandeep R Mehra
- Division of Cardiology Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
33
|
Left Ventricular Assist Device Salvage with Omental Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1250. [PMID: 28458965 PMCID: PMC5404436 DOI: 10.1097/gox.0000000000001250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/10/2017] [Indexed: 11/25/2022]
Abstract
A large number of people are affected with heart failure annually and require left ventricular assist device placement as a bridge to heart transplant or as destination therapy. When these devices become infected, it is a challenge to eradicate the infection. Failure ultimately results in a significant morbidity and mortality. Source control along with debridement and antibiotics can eradicate the infection of the patient, but many times there is a large defect that needs soft-tissue coverage. Many options for soft-tissue coverage have been suggested, but omentum may be an excellent choice due to its vascularity, bulk, and immunological properties. In this case report, the omental flap is employed for salvage of the left ventricular assist device with excellent results.
Collapse
|
34
|
Teuteberg JJ, Slaughter MS, Rogers JG, McGee EC, Pagani FD, Gordon R, Rame E, Acker M, Kormos RL, Salerno C, Schleeter TP, Goldstein DJ, Shin J, Starling RC, Wozniak T, Malik AS, Silvestry S, Ewald GA, Jorde UP, Naka Y, Birks E, Najarian KB, Hathaway DR, Aaronson KD. The HVAD Left Ventricular Assist Device: Risk Factors for Neurological Events and Risk Mitigation Strategies. JACC-HEART FAILURE 2016; 3:818-28. [PMID: 26450000 DOI: 10.1016/j.jchf.2015.05.011] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 05/20/2015] [Accepted: 05/26/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the risk factors for ischemic in hemorrhage cerebrovascular events in patients supported by the HeartWare ventricular assist device (HVAD). BACKGROUND Patients supported with left ventricular assist devices are at risk for both ischemic and hemorrhagic cerebrovascular events. METHODS Patients undergoing implantation with a HVAD as part of the bridge-to-transplant trial and subsequent continued access protocol were included. Neurological events (ischemic cerebrovascular accidents [ICVAs] and hemorrhagic cerebrovascular accidents [HCVAs]) were assessed, and the risk factors for these events were evaluated in a multivariable model. RESULTS A total of 382 patients were included: 140 bridge-to-transplant patients from the ADVANCE (Evaluation of the HeartWare Left Ventricular Assist Device for the Treatment of Advanced Heart Failure) clinical trial and 242 patients from the continued access protocol. Patients had a mean age of 53.2 years; 71.2% were male, and 68.1% were white. Thirty-eight percent had ischemic heart disease, and the mean duration of support was 422.7 days. The overall prevalence of ICVA was 6.8% (26 of 382); for HCVA, it was 8.4% (32 of 382). Pump design modifications and a protocol-driven change in the antiplatelet therapy reduced the prevalence of ICVA from 6.3% (17 of 272) to 2.7% (3 of 110; p = 0.21) but had a negligible effect on the prevalence of HVCA (8.8% [24 of 272] vs. 6.4% [7 of 110]; p = 0.69). Multivariable predictors of ICVA were aspirin ≤81 mg and atrial fibrillation; predictors of HCVA were mean arterial pressure >90 mm Hg, aspirin ≤81 mg, and an international normalized ratio >3.0. Eight of the 30 participating sites had established improved blood pressure management (IBPM) protocols. Although the prevalence of ICVA for those with and without IBPM protocols was similar (5.3% [6 of 114] vs. 5.2% [14 of 268]; p = 0.99), those with IBPM protocols had a significantly lower prevalence of HCVA (1.8% [2 of 114] vs. 10.8% [29 of 268]; p = 0.0078). CONCLUSIONS Anticoagulation, antiplatelet therapy, and blood pressure management affected the prevalence of cerebrovascular events after implantation of the HVAD. Attention to these clinical parameters can have a substantial impact on the occurrence of serious neurological events. (Evaluation of the HeartWare Left Ventricular Assist Device for the Treatment of Advanced Heart Failure [ADVANCE]; NCT00751972).
Collapse
Affiliation(s)
| | | | | | | | | | | | - Eduardo Rame
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert L Kormos
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | | | | | | | - Emma Birks
- University of Louisville, Louisville, Kentucky
| | | | | | | | | |
Collapse
|
35
|
Fakhro A, Jalalabadi F, Brown RH, Izaddoost SA. Treatment of Infected Cardiac Implantable Electronic Devices. Semin Plast Surg 2016; 30:60-5. [PMID: 27152097 DOI: 10.1055/s-0036-1580733] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With their rising benefits, cardiac implantable electronic devices (CIEDs) such as pacemakers and left ventricular assist devices (LVADs) have witnessed a sharp rise in use over the past 50 years. As indications for use broaden, so too does their widespread employment with its attendant rise of CIED infections. Such large numbers of infections have inspired various algorithms mandating treatment. Early diagnosis of inciting organisms is crucial to tailoring appropriate antibiotic and or antifungal treatment. In addition, surgical debridement and explant of the device have been a longstanding modality of care. More novel therapies focus on salvage of the device by way of serial washouts and instilling drug-eluting antibiotic impregnated beads into the wound. The wound is then serially debrided until clean and closed. This technique is better suited to patients whose device cannot be removed, patients who are poor candidates for cardiac surgery, or patients who have failed conventional prior treatments.
Collapse
Affiliation(s)
- Abdulla Fakhro
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Faryan Jalalabadi
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodger H Brown
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Shayan A Izaddoost
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
36
|
Husain S, Sole A, Alexander BD, Aslam S, Avery R, Benden C, Billaud EM, Chambers D, Danziger-Isakov L, Fedson S, Gould K, Gregson A, Grossi P, Hadjiliadis D, Hopkins P, Luong ML, Marriott DJ, Monforte V, Muñoz P, Pasqualotto AC, Roman A, Silveira FP, Teuteberg J, Weigt S, Zaas AK, Zuckerman A, Morrissey O. The 2015 International Society for Heart and Lung Transplantation Guidelines for the management of fungal infections in mechanical circulatory support and cardiothoracic organ transplant recipients: Executive summary. J Heart Lung Transplant 2016; 35:261-282. [DOI: 10.1016/j.healun.2016.01.007] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/10/2016] [Indexed: 01/10/2023] Open
|
37
|
Hussain A, Curry B, Cahalan L, Minkin S, Gartner M, Cahalan P. Development and in vitro evaluation of infection resistant materials: A novel surface modification process for silicone and Dacron. J Biomater Appl 2015; 30:1103-13. [DOI: 10.1177/0885328215607378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Silicone and Dacron are used in a wide spectrum of implantable and indwelling medical products. They elicit a foreign body response, which results in a chronic inflammatory environment and collagenous encapsulation of the medical device that compromises the immune system’s ability to effectively fight infections at the biomaterial surface. The objective of this work is to evaluate a novel process to modify silicone and Dacron with a bioactive collagen surface coupled to a gentamicin impregnated hydrogel graft and assess the surface’s cytocompatibility and infection resistance properties. Samples of silicone and polyethylene terephthalate (Dacron velour) were modified by plasma deposition and activation followed by a co-polymer acrylic acid (AA)/acrylamide (AAm) hydrogel graft and covalent immobilization of a bioactive collagen surface. The modified surfaces were characterized using FTIR, contact angle, staining, SEM, and XPS. The poly (AA-AAm) hydrogel was impregnated with gentamicin and tested for controlled release characteristics. Each modified surface was evaluated for its ability to resist infection and to promote normal healing as measured by bacterial growth inhibition ( Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa) in both broth and agar conditions as well as using fluorescence microscopy to observe adherence of 3T3-NIH fibroblasts. The addition of the poly (AA-AAm) hydrogel with gentamicin inhibited bacterial growth and the subsequent addition of the collagen surface promoted robust fibroblast adhesion on both silicone and Dacron materials. Thorough surface characterization and in vitro bacterial and fibroblast evaluation results suggest that this novel surface bioengineering process generated a highly effective surface on silicone and Dacron with the potential to reduce infection and promote healing.
Collapse
|
38
|
Towards destination therapy with left ventricular assist devices in Japan. Gen Thorac Cardiovasc Surg 2015; 63:537-9. [PMID: 26281777 DOI: 10.1007/s11748-015-0580-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Indexed: 12/13/2022]
|
39
|
Abstract
The percentage of elderly patients receiving left ventricular assist devices (LVADs) has increased; thus, a rise in the frequency of elderly prevalent diseases would be expected in LVAD-supported patients. Cancer is the second leading cause of death in the United States, and the frequency of cancer and the mortality rate of malignancies increase with age. We describe the clinical characteristics of eight patients who were diagnosed of cancer after LVAD implantation. Skin, esophageal, central nervous system (CNS), hematological and renal malignancies were observed. After careful consideration, these patients underwent surgical resections, radiotherapy, radiofrequency ablation, and chemotherapy with variable results. Patients who developed cancer were older males who received LVAD predominantly as destination therapy. Skin cancer and hematological malignancy were managed with standard oncologic treatment. Renal cell carcinoma was monitored, and a CNS tumor was treated aggressively but as expected had a poor outcome. Esophageal cancer, although localized, represented a serious therapeutic challenge, as patients were unable to undergo a potentially curative surgical procedure because of the anatomic location of malignancy. More information is needed regarding the outcomes and best treatment strategies for this newly identified population.
Collapse
|
40
|
Imamura T, Kinugawa K, Nitta D, Inaba T, Maki H, Hatano M, Kinoshita O, Nawata K, Kyo S, Ono M. Readmission due to driveline infection can be predicted by new score by using serum albumin and body mass index during long-term left ventricular assist device support. J Artif Organs 2015; 18:120-7. [PMID: 25604148 DOI: 10.1007/s10047-015-0816-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/26/2014] [Indexed: 01/21/2023]
Abstract
Survival in patients with continuous flow left ventricular assist device (CF LVAD) had been increased owing to improved perioperative management procedures. The second target for successful long-term LVAD treatment was to reduce readmission especially due to device-specific infection, which was one of the major unsolved complications. Among 57 enrolled patients who had received CF LVAD and been followed for 530 days on median at our institute between 2008 and 2014, 21 patients experienced readmission due to driveline infection (DLI) at 190 days after the surgery on median. Considering the result of Uni/Multivariate Cox regression analyses demonstrating lower serum albumin concentration (S-ALB) (hazard ratio 0.144) and body mass index (BMI) (hazard ratio 0.843) both obtained at discharge were independent predictors of readmission due to DLI, we constructed a New Score "7 × [S-ALB (g/dL)] + [BMI]", which significantly stratified readmission-free rate into 3 groups [low (>50 Pt), intermediate (44-50 Pt), and high risk group (<44 Pt)] during 2-year study period (p = 0.008). Survival remained unchanged irrespective of DLI, whereas those with DLI needed longer in-hospital treatment (p < 0.05). In conclusion, readmission due to DLI could be predicted by using two simple nutrition parameters at discharge. Early nutrition assessment and intervention may reduce readmission and improve patients' quality of life during long-term LVAD support.
Collapse
Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Zuckermann A, Schulz U, Deuse T, Ruhpawar A, Schmitto JD, Beiras-Fernandez A, Hirt S, Schweiger M, Kopp-Fernandes L, Barten MJ. Thymoglobulin induction in heart transplantation: patient selection and implications for maintenance immunosuppression. Transpl Int 2014; 28:259-69. [PMID: 25363471 PMCID: PMC4359038 DOI: 10.1111/tri.12480] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/18/2014] [Accepted: 10/24/2014] [Indexed: 01/12/2023]
Abstract
Clinical data relating to rabbit antithymocyte globulin (rATG) induction in heart transplantation are far less extensive than for other immunosuppressants, or indeed for rATG in other indications. This was highlighted by the low grade of evidence and the lack of detailed recommendations for prescribing rATG in the International Society for Heart and Lung Transplantation (ISHLT) guidelines. The heart transplant population includes an increasing frequency of patients on mechanical circulatory support (MCS), often with ongoing infection and/or presensitization, who are at high immunological risk but also vulnerable to infectious complications. The number of patients with renal impairment is also growing due to lengthening waiting times, intensifying the need for strategies that minimize calcineurin inhibitor (CNI) toxicity. Additionally, the importance of donor-specific antibodies (DSA) in predicting graft failure is influencing immunosuppressive regimens. In light of these developments, and in view of the lack of evidence-based prescribing criteria, experts from Germany, Austria, and Switzerland convened to identify indications for rATG induction in heart transplantation and to develop an algorithm for its use based on patient characteristics.
Collapse
Affiliation(s)
- Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Toda K, Sawa Y. Clinical management for complications related to implantable LVAD use. Gen Thorac Cardiovasc Surg 2014; 63:1-7. [DOI: 10.1007/s11748-014-0480-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Indexed: 11/28/2022]
|
43
|
John R, Aaronson KD, Pae WE, Acker MA, Hathaway DR, Najarian KB, Slaughter MS. Drive-line infections and sepsis in patients receiving the HVAD system as a left ventricular assist device. J Heart Lung Transplant 2014; 33:1066-73. [DOI: 10.1016/j.healun.2014.05.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 05/02/2014] [Accepted: 05/28/2014] [Indexed: 10/25/2022] Open
|
44
|
Ishibashi-Ueda H, Ikeda Y, Matsuyama TA, Ohta-Ogo K, Sato T, Seguchi O, Yanase M, Fujita T, Kobayashi J, Nakatani T. The pathological implications of heart transplantation: Experience with 50 cases in a single center. Pathol Int 2014; 64:423-31. [DOI: 10.1111/pin.12189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 07/05/2014] [Indexed: 01/24/2023]
Affiliation(s)
- Hatsue Ishibashi-Ueda
- Department of Pathology; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Yoshihiko Ikeda
- Department of Pathology; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Taka-aki Matsuyama
- Department of Pathology; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Keiko Ohta-Ogo
- Department of Pathology; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Takuma Sato
- Department of Transplantation; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Osamu Seguchi
- Department of Transplantation; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Masanobu Yanase
- Department of Transplantation; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| | - Takeshi Nakatani
- Department of Transplantation; National Cerebral and Cardiovascular Center; Suita Osaka Japan
| |
Collapse
|
45
|
Operative modification for the prevention of device-related infection during NIPRO extracorporeal left ventricular assist device implantation. J Artif Organs 2014; 17:220-7. [PMID: 24723254 DOI: 10.1007/s10047-014-0766-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 03/25/2014] [Indexed: 10/25/2022]
Abstract
An operative modification in which the NIPRO left ventricular assist device (LVAD) cannulas are passed through the intraperitoneal cavity is performed as the first-choice standard technique in our institution. Eighteen consecutive patients who underwent NIPRO LVAD implantation as heart transplantation candidates were enrolled in this study. The cannulas were passed through the intraperitoneal cavity in 11 patients (Group IP) and the extraperitoneal space in 7 patients (Group EP). A device-related major infection was defined as bloodstream infection and/or abscess formation in the deep tissue space. Device-related major infection occurred in 6 patients in Group IP and in 6 patients in Group EP. Of these patients, 3 patients in Group IP and 5 patients in Group EP suffered from uncontrollable bloodstream infection and finally died of development into multiple organ failure and/or cerebrovascular accidents. The actuarial rates of freedom from device-related major infection at 6 months after LVAD implantation were 100 % in Group IP and 38 % in Group EP, respectively (p = 0.02). Moreover, the actuarial survival rates after the initial device-related major infection in Group IP could be significantly higher than in Group EP (83 and 67 % at 6 months, p = 0.03). We demonstrated that this operative modification can contribute to prevention of progression of superficial skin infection to critical infection and to extension of the survival duration after the initial device-related major infection.
Collapse
|
46
|
Abstract
BACKGROUND The use of left ventricular assist devices has become common for the treatment of end-stage heart failure, both as a bridge to transplantation and as destination therapy. The nature of these devices and the comorbid conditions of the patients in whom the devices are implanted lead to high rates of device infection that are related directly to mortality. METHODS Over 2 years, the senior author (S.A.I.) treated 26 patients with left ventricular assist device infections, ranging from superficial driveline infections to deeper pocket infections and device infections. An algorithm involving the use of repeated débridement and placement of antibiotic beads was used in treatment of these infections. Once cleared of infection, patients were treated with definitive closure or flap coverage of the formerly infected device component. RESULTS Seventeen of 26 patients with left ventricular assist device-related infections were cleared of their infection using this method. Ten of these patients underwent flap coverage of the device after their infection was cleared. In patients that were cleared of infection, mortality was 29 percent, whereas patients with recalcitrant infections had a mortality of 67 percent over the course of the study. CONCLUSIONS A systematic approach to treating left ventricular assist device-related infections has the potential to treat and clear these infections, with promising overall survival rates. This proposed algorithm led to high infection clearance rates compared with previously published literature. Infection clearance in patients on left ventricular assist device destination therapy may result in mortality rates approaching those of their uninfected peers.
Collapse
|
47
|
Nienaber J, Wilhelm MP, Sohail MR. Current concepts in the diagnosis and management of left ventricular assist device infections. Expert Rev Anti Infect Ther 2014; 11:201-10. [DOI: 10.1586/eri.12.163] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
48
|
Hessel EA. Management of patients with implanted ventricular assist devices for noncardiac surgery: a clinical review. Semin Cardiothorac Vasc Anesth 2013; 18:57-70. [PMID: 24132353 DOI: 10.1177/1089253213506788] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
While originally primarily used as bridge to cardiac transplantation and bridge to recovery, more commonly ventricular assist devices (VADs) are being inserted as destination therapy. These patients are being discharged from transplant and mechanical assist centers, living as outpatients, and thus the pool of community-dwelling patients with VADs continues to expand. Not infrequently they present for surgical procedures either directly related to the device itself or more often incidental to the fact that they have a VAD. This scenario may be more common in patients with VADs placed for destination therapy because these patients tend to be older and have more comorbidities and are living longer with their device. Thus, it is important for all anesthesiologists to be aware of the special anesthesia needs of patients with VADs requiring noncardiac surgery.
Collapse
Affiliation(s)
- Eugene A Hessel
- 1University of Kentucky College of Medicine, Lexington, KY, USA
| |
Collapse
|
49
|
Abstract
Left ventricular assist devices have been proven to be superior to medical therapy for advanced heart failure patients awaiting heart transplantation and viable alternatives to transplantation for destination therapy patients. Improvements in the design of ventricular assist devices have been rewarded by a decrease in adverse events and an increase in survival. Despite significant progress, even the latest generation left ventricular assist devices are burdened by a significant long-term adverse events profile that will increasingly challenge physicians as patients survive longer on implantable mechanical circulatory support. In this review, we analyze the impact of long-term adverse events on clinical outcomes in the major trials of continuous flow left ventricular assist devices. We discuss several of the more pertinent and interesting adverse events, examine their potential causes, and explore their future implications.
Collapse
|
50
|
Koval CE, Rakita R. Ventricular assist device related infections and solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:348-54. [PMID: 23465027 DOI: 10.1111/ajt.12126] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- C E Koval
- Department of Infectious Disease, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | | | | |
Collapse
|