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Shih H, Mondellini GM, Kurlansky PA, Sun J, Ning Y, Feldman VR, Tiburcio M, Maguire CW, Ladanyi A, Clerkin K, Naka Y, Sayer GT, Uriel N, Colombo PC, Takeda K, Yuzefpolskaya M. Unplanned hospital readmissions following HeartMate 3 implantation: Readmission rates, causes, and impact on survival. Artif Organs 2024. [PMID: 38825957 DOI: 10.1111/aor.14763] [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: 12/12/2023] [Revised: 03/12/2024] [Accepted: 04/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Hospital readmissions following left ventricular assist device (LVAD) remain a frequent comorbidity, associated with decreased quality of life and increased resources utilization. This study sought to determine causes, predictors, and impact on survival of hospitalizations during HeartMate 3 (HM3) support. METHODS All patients implanted with HM3 between November 2014 to December 2019 at Columbia University Irving Medical Center were consecutively enrolled in the study. Demographics and clinical characteristics from the index admission and the first outpatient visit were collected and used to estimate 1-year and 900-day readmission-free survival and overall survival. Multivariable analysis was performed for subsequent readmissions. RESULTS Of 182 patients who received a HM3 LVAD, 167 (92%) were discharged after index admission and experienced 407 unplanned readmissions over the median follow up of 727 (interquartile range (IQR): 410.5, 1124.5) days. One-year and 900-day mean cumulative number of all-cause unplanned readmissions was 0.43 (95%CI, 0.36, 0.51) and 1.13 (95%CI, 0.99, 1.29). The most frequent causes of rehospitalizations included major infections (29.3%), bleeding (13.2%), device-related (12.5%), volume overload (7.1%), and other (28%). One-year and 900-day survival free from all-cause readmission was 38% (95%CI, 31-46%) and 16.6% (95%CI, 10.3-24.4%). One-year and 900-day freedom from 2, 3, and ≥4 readmissions were 60.7%, 74%, 74.5% and 26.2%, 33.3%, 41.3%. One-year and 900-day survival were unaffected by the number of readmissions and remained >90%. Male sex, ischemic etiology, diabetes, lower serum creatinine, longer duration of index hospitalization, and a history of readmission between discharge and the first outpatient visit were associated with subsequent readmissions. CONCLUSIONS Unplanned hospital readmissions after HM3 are common, with infections and bleeding accounting for the majority of readmissions. Irrespective of the number of readmissions, one-year survival remained unaffected.
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Affiliation(s)
- Hueyjong Shih
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Giulio M Mondellini
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Paul A Kurlansky
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York, USA
| | - Jocelyn Sun
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York, USA
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York, USA
| | - Vivian R Feldman
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Melie Tiburcio
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Conor W Maguire
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Annamaria Ladanyi
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Kevin Clerkin
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Gabriel T Sayer
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Nir Uriel
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
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2
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Schachl J, Stoiber M, Socha M, Zimpfer D, Wiedemann D, Schima H, Schlöglhofer T. Mechanical Characterization of Anchoring Devices for the Prevention of Driveline Infection in Left Ventricular Assist Device Patients. ASAIO J 2024; 70:249-256. [PMID: 38081043 DOI: 10.1097/mat.0000000000002111] [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: 04/04/2024] Open
Abstract
Driveline infection (DLI) is associated with increased mortality and morbidity in left ventricular assist device (LVAD) patients. Because trauma to the driveline exit-site (DLES) is a risk factor for DLI, adhesive anchoring devices are used to immobilize the DL. In this study, commonly used products (identified through literature review and contact with nine international VAD implantation centers) were mechanically characterized to evaluate their effectiveness in preventing DLES trauma. Eight devices were tested in an in vitro abdominal model of the DLES, where a tensile force (10 N) was applied to a HeartMate 3 DL, whereas the resulting force ( FTotal ) on the DLES was recorded using a three-axis load cell. Four devices (CathGrip: FTotal = 2.1 ± 0.4 N, Secutape: FTotal = 2.6 ± 0.3 N, Hollister: FTotal = 2.7 ± 0.5 N, Tubimed: FTotal = 2.9 ± 0.2 N) were significantly ( p < 0.05) better at preventing tensile forces at the DLES compared to the other four devices (Main-Lock: FTotal = 3.7 [0.7] N, Secutape sensitive: FTotal = 3.9 ± 0.4 N, Foley Anchor: FTotal = 4.3 ± 0.5 N, Grip-Lok: FTotal = 5.4 ± 0.8 N). Immobilization of the DL with each anchoring device resulted in lower tensile force on the DLES than without an anchor ( FTotal = 8.2 ± 0.3 N). In conclusion, the appropriate selection of anchoring devices plays a critical role in reducing the risk of DLI, whereas the CathGrip, Secutape, Hollister, or Tubimed were superior in preventing trauma to the DLES in this study.
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Affiliation(s)
- Johanna Schachl
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Stoiber
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Martina Socha
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Heinrich Schima
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Thomas Schlöglhofer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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3
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Eckmann C, Sunderkötter C, Becker K, Grabein B, Hagel S, Hanses F, Wichmann D, Thalhammer F. Left ventricular assist device-associated driveline infections as a specific form of complicated skin and soft tissue infection/acute bacterial skin and skin structure infection - issues and therapeutic options. Curr Opin Infect Dis 2024; 37:95-104. [PMID: 38085707 PMCID: PMC10911258 DOI: 10.1097/qco.0000000000000999] [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] [Indexed: 01/16/2024]
Abstract
PURPOSE OF REVIEW This review comments on the current guidelines for the treatment of wound infections under definition of acute bacterial skin and skin structure infections (ABSSSI). However, wound infections around a catheter, such as driveline infections of a left ventricular assist device (LVAD) are not specifically listed under this definition in any of the existing guidelines. RECENT FINDINGS Definitions and classification of LVAD infections may vary across countries, and the existing guidelines and recommendations may not be equally interpreted among physicians, making it unclear if these infections can be considered as ABSSSI. Consequently, the use of certain antibiotics that are approved for ABSSSI may be considered as 'off-label' for LVAD infections, leading to rejection of reimbursement applications in some countries, affecting treatment strategies, and hence, patients' outcomes. However, we believe driveline exit site infections related to LVAD can be included within the ABSSSI definition. SUMMARY We argue that driveline infections meet the criteria for ABSSSI which would enlarge the 'on-label' antibiotic armamentarium for treating these severe infections, thereby improving the patients' quality of life.
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Affiliation(s)
- Christian Eckmann
- Academic Hospital of Goettingen University, Department of General, Visceral and Thoracic Surgery, Klinikum Hannoversch-Muenden, Hannoversch-Muenden
| | - Cord Sunderkötter
- Martin-Luther-University Halle-Wittenberg, University and University Hospital of Halle, Department of Dermatology and Venerology, Halle
| | - Karsten Becker
- University Medicine Greifswald, Friedrich Loeffler-Institute of Medical Microbiology, Greifswald
| | - Béatrice Grabein
- LMU Hospital, Clinical Microbiology and Hospital Hygiene, Munich
| | - Stefan Hagel
- Jena University Hospital-Friedrich Schiller University Jena, Institute for Infectious Diseases and Infection Control, Jena
| | - Frank Hanses
- University Hospital Regensburg, Department of Infection Prevention and Infectious Diseases
- University Hospital Regensburg, Emergency Department, Regensburg
| | - Dominic Wichmann
- University Medical Center Hamburg-Eppendorf, Department of Intensive Care Medicine, Hamburg
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Balestra N, Fredericks S, Silva AVCD, Rodrigues RCM, Nunes DP, Pedrosa RBDS. Driveline dressings used in heartmate patients and local complications: A retrospective cohort. Heart Lung 2023; 62:271-277. [PMID: 37633011 DOI: 10.1016/j.hrtlng.2023.08.007] [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: 04/25/2023] [Revised: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Patients with long-term ventricular assist devices (VAD) are predisposed to infection, bleeding, and pressure injuries at the insertion of the driveline. There is no consensus on a driveline dressing protocol. Chlorhexidine is often used to clean the driveline exit site and has been associated with lower rates of infection. For driveline coverage, bacteriostatic agents and transparent film have shown good results, but are costly. The same issue was associated with anchorage devices. OBJECTIVES The purpose of this study was to evaluate the types of dressings used in the driveline of patients using HeartMate (HM) and to describe the incidence density of local complications (infection, bleeding, and pressure injury) within 30 days postoperatively. METHODS A retrospective cohort study was conducted and included 22 patients admitted to the Intensive Care Unit after implantation of HM II and III in a Brazilian private hospital. RESULTS Several types of dressings were used in the drivelines. There were 22 different types of dressings. Dressing type 6 (Chlorhexidine, Excilon, Gauze and IV3000) were the most used (45.4%). Subjects using the Flexi-Trak anchoring device had a higher rate of local bleeding (50.0%) and those who used the Hollister device had more infection (61.1%) and pressure injury associated with a medical device (11.1%), compared to others. Infection was the primary complication (45.4%), followed by local bleeding (27.7%). CONCLUSION Despite the high variability of products used in the driveline of patients using HeartMate, the dressing made with chlorhexidine, silver-impregnated absorbent foam and transparent film, and the use of anchoring devices was the most frequently used. Infection was the most common complication.
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Affiliation(s)
- Natalia Balestra
- Sírio-Libanês Hospital, 115 Dona Adma Jafet St, São Paulo, 01308-050, Brazil; Faculty of Nursing, University of Campinas (UNICAMP), 126 Tessália Vieira de Camargo St, Campinas, 13083-887, Brazil
| | - Suzanne Fredericks
- Daphne Cockwell School of Nursing, Toronto Metropolitan University, 350 Victoria St, Toronto, M5B 2K3, Canada
| | | | | | - Daniella Pires Nunes
- Faculty of Nursing, University of Campinas (UNICAMP), 126 Tessália Vieira de Camargo St, Campinas, 13083-887, Brazil
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5
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Tsuji M, Kakuda N, Bujo C, Saito A, Ishida J, Amiya E, Hatano M, Shimada A, Imai H, Kimura M, Ando M, Kinoshita O, Yamauchi H, Komuro I, Ono M. Prophylactic negative pressure wound therapy is not effective for preventing driveline infection following left ventricular assist device implantation. Artif Organs 2023; 47:566-573. [PMID: 36300650 DOI: 10.1111/aor.14440] [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: 05/13/2022] [Revised: 09/10/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Driveline infection (DLI) following left ventricular assist device (LVAD) implantation remains an unresolved problem. Negative pressure wound therapy (NPWT) promotes wound healing by applying negative pressure on the surface of the wound. Recently, the prophylactic application of NPWT to closed surgical incisions has decreased surgical site infections in various postsurgical settings. Therefore, we evaluated the efficacy and safety of prophylactic NPWT for preventing DLI in patients with LVAD implantation. METHODS Prophylactic NPWT was provided to 50 patients who received continuous-flow LVADs as bridge-to-transplant therapy at our institution between May 2018 and October 2020 (NPWT group). The negative pressure dressing was applied immediately after surgery and retained on the driveline exit site for 7 days with a continuous application of -125 mm Hg negative pressure. The primary outcome was DLI within 1 year of LVAD implantation. We compared the rate of DLI incidence in the NPWT group with that in the historical control cohort (50 patients) treated with the standard dressing (SD) who received LVAD implantation between July 2015 and April 2018 (SD group). RESULTS No severe complications were associated with the NPWT. During the follow-up period, DLI was diagnosed in 16 participants (32%) in the NPWT group and 21 participants (42%) in the SD group. The rates of DLI incidence and freedom from DLI did not differ between groups (p = 0.30 and p = 0.63). CONCLUSIONS Prophylactic NPWT at the driveline exit site was safe following LVAD implantation. However, it did not significantly reduce the risk of DLI.
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Affiliation(s)
- Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Advanced Medical Center for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Asako Shimada
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroko Imai
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Kinoshita
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruo Yamauchi
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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6
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Mutsuga M, Okumura T, Morimoto R, Kondo T, Ito H, Terazawa S, Tokuda Y, Narita Y, Nishida K, Murohara T, Usui A. Impact of an improved driveline management for HeartMate II and HeartMate 3 left ventricular assist devices. Artif Organs 2023; 47:387-395. [PMID: 36269680 DOI: 10.1111/aor.14426] [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: 04/04/2022] [Revised: 07/14/2022] [Accepted: 10/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND We evaluated the impact of a standardized driveline care strategy, including a subfascial-tunneling method and dressing protocol, on the incidence of driveline infection (DLI). METHODS DLI data from all HeartMate II (HMII) and HeartMate 3 (HM3) patients (including exchange devices) were retrospectively collected between 2013 and 2021. The driveline subfascial-tunneling method was altered in three steps (A: right direct; B: left triple, C: right triple), and the shower protocol was changed in two steps (A: with/without cover, B: with cover). Disinfection was individually tailored after changing the shower protocol. Complications associated with morbidity and mortality were evaluated for each modification. RESULTS During the study period, 80 devices were implanted (HMII, n = 54; HM3, n = 26). The 8-year incidence of DLI was 15% (n = 8) in HMII patients and 0% in HM3 patients (p = 0.039). DLI was not associated with hospital mortality. The modified dressing protocol and tunneling method was associated with a significantly better DLI incidence rate in comparison to the previous one: Protocol-A (n = 17), Protocol-B (n = 63), 35% vs 3% (p = 0.0009), Method-A (n = 13), Method-B (n = 42), Method-C (n = 25), 46% vs 5% vs 0% (p = 0.0001). The rete of freedom form DLI at 1, 2, and 3 years had also significant difference between groups: Protocol-A and Protocol-B, 80%, 54%, 54% vs 96%, 96%, 96%, respectively (p < 0.0001), Method-A, Method-B and Method-C, 76%, 44%, 44%, vs 94%, 94%, 94% vs 100%, 100%, respectively (p < 0.0001). CONCLUSIONS A standardized triple driveline tunneling strategy and waterproof dressing protocol reduced driveline infection in HM3 patients to 0%.
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Affiliation(s)
- Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Ito
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sachie Terazawa
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuji Narita
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Nishida
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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7
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Lumish HS, Cagliostro B, Braghieri L, Bohn B, Mondellini GM, Antler K, Feldman V, Kleet A, Murphy J, Tiburcio M, Fidlow K, Jennings D, Sayer GT, Takeda K, Naka Y, Demmer RT, Aaron JG, Uriel N, Colombo PC, Yuzefpolskaya M. Driveline Infection in Left Ventricular Assist Device Patients: Effect of Standardized Protocols, Pathogen Type, and Treatment Strategy. ASAIO J 2022; 68:1450-1458. [PMID: 35239537 PMCID: PMC9469917 DOI: 10.1097/mat.0000000000001690] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Driveline infection (DLI) is common after left ventricular assist device (LVAD). Limited data exist on DLI prevention and management. We investigated the impact of standardized driveline care initiatives, specific pathogens, and chronic antibiotic suppression (CAS) on DLI outcomes. 591 LVAD patients were retrospectively categorized based on driveline care initiatives implemented at our institution (2009-2019). Era (E)1: nonstandardized care; E2: standardized driveline care protocol; E3: addition of marking driveline exit site; E4: addition of "no shower" policy. 87(15%) patients developed DLI at a median (IQR) of 403(520) days. S. aureus and P. aeruginosa were the most common pathogens. 31 (36%) of DLI patients required incision and drainage (I&D) and 5 (5.7%) device exchange. P. aeruginosa significantly increased risk for initial I&D (HR 2.7, 95% CI, 1.1-6.3) and recurrent I&D or death (HR 4.2, 95% CI, 1.4-12.5). Initial I&D was associated with a significant increased risk of death (HR 2.92 (1.33-6.44); P = 0.008) when compared to patients who did not develop DLI. Implementation of standardized driveline care protocol (E2) was associated with increased 2-year freedom from DLI compared to nonstandardized care (HR 0.36, 95% CI, 0.2-0.6, P < 0.01). Additional preventive strategies (E3&E4) showed no further reduction in DLI rates. 57(65%) DLI patients received CAS, 44% of them required escalation to intravenous antibiotics and/or I&D. Presence of P. aeruginosa DLI markedly increased risk for I&D or death. Conditional survival of patients progressing to I&D is diminished. Standardized driveline care protocol was associated with a significant reduction in DLI, while additional preventive strategies require further testing.
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Affiliation(s)
- Heidi S. Lumish
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Barbara Cagliostro
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Bruno Bohn
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Giulio M. Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Karen Antler
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Vivian Feldman
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Audrey Kleet
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jennifer Murphy
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Melie Tiburcio
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Kathryn Fidlow
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Douglas Jennings
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T. Sayer
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Ryan T. Demmer
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
| | - Justin G. Aaron
- Department of Medicine Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Paolo C. Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Paolo C. Colombo and Melana Yuzefpolskaya contributed equally to this study
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Paolo C. Colombo and Melana Yuzefpolskaya contributed equally to this study
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8
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Seretny J, Pidborochynski T, Buchholz H, Freed DH, MacArthur R, Dubyk N, Cunliffe L, Zelaya O, Conway J. Decreasing driveline infections in patients supported on ventricular assist devices: a care pathway approach. BMJ Open Qual 2022; 11:bmjoq-2022-001815. [PMID: 35649636 PMCID: PMC9161071 DOI: 10.1136/bmjoq-2022-001815] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
Background Driveline infections (DLIs) are a common adverse event in patients on ventricular assist devices (VADs) with incidence ranging from 14% to 59%. DLIs have an impact on patients and the healthcare system with efforts to prevent DLIs being essential. Prior to our intervention, our program had no standard driveline management presurgery and postsurgery. The purpose of this Quality Improvement (QI) initiative was to reduce DLIs and related admissions among patients with VAD within the first year post implant. Methods In anticipation of the QI project, we undertook a review of the programs’ current driveline management procedures and completed a survey with patients with VAD to identify current barriers to proper driveline management. Retrospective data were collected for a pre-QI intervention baseline comparison group, which included adult patients implanted with a durable VAD between 1 January 2017 and 31 July 2018. A three-pronged care pathway (CP) was initiated among patients implanted during August 2018 to July 2019. The CP included standardised intraoperative, postoperative and predischarge teaching initiatives and tracking. Using statistical process control methods, DLIs and readmissions in the first year post implant were compared between patients in the CP group and non-CP patients. P-charts were used to detect special cause variation. Results A higher proportion of CP group patients developed a DLI in the first year after implant (52% vs 32%). None developed a DLI during the index admission, which differed from the non-CP group and met criteria for special cause variation. There was a downward trend in cumulative DLI-related readmissions among CP group patients (55% vs 67%). There was no association between CP compliance and development of DLIs within 1 year post implant. Conclusion The CP did not lead to a reduction in the incidence of DLIs but there was a decrease in the proportion of patients with DLIs during their index admission and those readmitted for DLIs within 1 year post implant. This suggests that the CP played a role in decreasing the impact of DLIs in this patient population. However, given the short time period of follow-up longer follow-up will be required to look for sustained effects.
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Affiliation(s)
- Julia Seretny
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Tara Pidborochynski
- Pediatric Cardiology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Holger Buchholz
- Department of Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Darren H Freed
- Department of Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Roderick MacArthur
- Department of Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Nicole Dubyk
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Laura Cunliffe
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Osiris Zelaya
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Pediatric Cardiology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
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9
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Saeed O, Moss N, Barrus B, Vidula H, Shah S, Feitell S, Masser KS, Kilic A, Moin D, Atluri P, Barati E. Preventing Driveline Infection during Left Ventricular Assist Device Support by the HeartMate 3: A Survey-Based Study. Artif Organs 2022; 46:1409-1414. [PMID: 35083754 DOI: 10.1111/aor.14187] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/30/2021] [Accepted: 01/07/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Driveline infection (DLI) is a significant source of morbidity and mortality during left ventricular assist device (LVAD) support yet limited studies are available to describe center-level prevalence, preventive practices and their potential effectiveness. METHODS We surveyed LVAD centers in the United States to determine program burden and preventive practices for DLI during HeartMate (HM) 3 support. An online, anonymous, question-based survey was sent to expert providers at implanting centers. Only a single respondent completed the survey for each center. As an exploratory analysis, we compared specific DLI preventive practices between centers with low (≤10%) and high (>10%) reported prevalence of DLI. RESULTS Seventy-eight centers responded to the survey (response rate: 50%). Respondent were comprised of 37 (47%) heart failure cardiologists, 27 (35%) LVAD coordinators and 14 (18%) cardiothoracic surgeons. The prevalence of DLI during HM3 was reported as ≤10% by 27 (35%), 11-25% by 36 (46%) and >25% by 16 (19%) of centers. Thirteen (17%) centers had a body mass index threshold for device placement, 29 (37%) utilized a counter incision, 66 (81%) placed an anchor stitch and 69 (88%) used an external device to stabilize the DL. Proportionally more centers with a low DLI prevalence used a wound vacuum 6(22%) vs. 3(6%, p=0.03) than those with high DLI. CONCLUSION Variation exists in reported prevalence and practices of preventing and managing driveline infections across centers during HM3 support. Further studies are warranted to develop and assess the effectiveness of standardized preventive strategies.
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Affiliation(s)
- Omar Saeed
- Department of Medicine (Cardiology), Montefiore Medical Center, Bronx, NY, USA
| | - Noah Moss
- Department of Medicine (Cardiology), Mount Sinai Medical Center, New York, NY, USA
| | - Bryan Barrus
- Department of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Himabindu Vidula
- Department of Medicine (Cardiology), University of Rochester Medical Center, Rochester, NY, USA
| | - Samit Shah
- Department of Medicine (Cardiology), NorthWell Health, Manhasset, NY, USA
| | - Scott Feitell
- Department of Medicine (Cardiology), Rochester Regional Medical Center, Bronx, NY, USA
| | | | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Danyaal Moin
- Department of Medicine (Cardiology), Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Barati
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
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10
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Shore S, Pienta MJ, Watt TMF, Yost G, Townsend WA, Cabrera L, Fetters MD, Chenoweth C, Aaronson KD, Pagani FD, Likosky DS. Non-patient factors associated with infections in LVAD recipients: A scoping review. J Heart Lung Transplant 2022; 41:1-16. [PMID: 34801350 PMCID: PMC9094089 DOI: 10.1016/j.healun.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/08/2021] [Accepted: 10/02/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Infections are the most common complication in recipients of durable left ventricular assist devices (LVAD) and are associated with increased morbidity, mortality, and expenditures. The existing literature examining factors associated with infection in LVAD recipients is limited and principally comprises single-center studies. This scoping review synthesizes all available evidence related to identifying modifiable, non-patient factors associated with infections among LVAD recipients. METHODS Published studies were identified through searching 5 bibliographic databases: PubMed, Scopus, EMBASE, CINAHL, and Web of Science Core Collection. Inclusion criteria required examination of factors associated with infections among recipients of contemporary, implantable, continuous flow LVADs. Key study characteristics were extracted by 4 independent reviewers and current literature described narratively. The Systems Engineering Initiative for Patient Safety (SEIPS) model was used to develop a taxonomy for non-patient related factors (e.g., tasks, tools, technologies, organization, and environment) associated with infections following LVAD implantation. All analyses took place between February 2019 and May 2021. FINDINGS A total of 43 studies met inclusion criteria. The majority of included studies were observational (n = 37), single-center (n = 29), from the U.S. (n = 38), and focused on driveline infections (n = 40). Among the 22 evaluated sub-domains of non-patient related factors, only two: increasing center experience and establishing a silicone-skin interface at the driveline exit site, were identified as consistently being associated with a lower risk of infection. CONCLUSION This review identified 43 studies that described non-patient related factors associated with infection in LVAD recipients. Only two factors were consistently associated with lower infection risk in LVAD recipients: increasing experience and establishing a silicone-skin interface at driveline exit site. The large variability in reporting across multiple studied interventions limited the ability to discern their effectiveness.
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Affiliation(s)
| | | | | | | | - Whitney A Townsend
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
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11
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Castrodeza J, Ortiz-Bautista C, Fernández-Avilés F. Continuous-flow left ventricular assist device: Current knowledge, complications, and future directions. Cardiol J 2021; 29:293-304. [PMID: 34967940 PMCID: PMC9007493 DOI: 10.5603/cj.a2021.0172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022] Open
Abstract
Long-term continuous-flow left ventricular assist devices have become a real alternative to heart transplantation in patients with advanced heart failure, achieving a promising 2-year event-free survival rate with new-generation devices. Currently, this technology has spread throughout the world, and any cardiologist or cardiac surgeon should be familiar with its fundamentals and its possible complications as well as the advances made in recent years. The aim of this review is to describe current knowledge, management of complications, and future directions of this novel heart-failure therapy.
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Affiliation(s)
- Javier Castrodeza
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain.
- CIBER de Enfermedades Cardiovasculares (CIBER - CV), Spain.
| | - Carlos Ortiz-Bautista
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBER - CV), Spain
| | - Francisco Fernández-Avilés
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBER - CV), Spain
- Universidad Complutense, Madrid, Spain
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12
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Pienta M, Shore S, Pagani FD, Likosky DS. Rates and types of infections in left ventricular assist device recipients: A scoping review. JTCVS OPEN 2021; 8:405-411. [PMID: 36004147 PMCID: PMC9390679 DOI: 10.1016/j.xjon.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/06/2021] [Indexed: 01/14/2023]
Affiliation(s)
- Michael Pienta
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Supriya Shore
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Mich
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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13
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Gustafsson F, Ben Avraham B, Chioncel O, Hasin T, Grupper A, Shaul A, Nalbantgil S, Hammer Y, Mullens W, Tops LF, Elliston J, Tsui S, Milicic D, Altenberger J, Abuhazira M, Winnik S, Lavee J, Piepoli MF, Hill L, Hamdan R, Ruhparwar A, Anker S, Crespo-Leiro MG, Coats AJS, Filippatos G, Metra M, Rosano G, Seferovic P, Ruschitzka F, Adamopoulos S, Barac Y, De Jonge N, Frigerio M, Goncalvesova E, Gotsman I, Itzhaki Ben Zadok O, Ponikowski P, Potena L, Ristic A, Jaarsma T, Ben Gal T. HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge. ESC Heart Fail 2021; 8:4425-4443. [PMID: 34585525 PMCID: PMC8712918 DOI: 10.1002/ehf2.13590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/22/2021] [Accepted: 08/19/2021] [Indexed: 12/28/2022] Open
Abstract
The growing population of left ventricular assist device (LVAD)‐supported patients increases the probability of an LVAD‐ supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient‐device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD‐supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non‐cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end‐of‐life approaches are described.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Binyamin Ben Avraham
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C., Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Tal Hasin
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Avishai Grupper
- Heart Failure Institute, Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aviv Shaul
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Yoav Hammer
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, University Hasselt, Hasselt, Belgium
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeremy Elliston
- Anesthesiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven Tsui
- Transplant Unit, Royal Papworth Hospital, Cambridge, UK
| | - Davor Milicic
- Department for Cardiovascular Diseases, Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Johann Altenberger
- SKA-Rehabilitationszentrum Großgmain, Salzburger, Straße 520, Großgmain, 5084, Austria
| | - Miriam Abuhazira
- Department of Cardiothoracic Surgery, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stephan Winnik
- Department of Cardiology, University Heart Center, University Hospital Zurich, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Jacob Lavee
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Lorrena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Righab Hamdan
- Department of Cardiology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefan Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marisa Generosa Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, Instituto de Investigacion Biomedica A Coruña (INIBIC), Universidad de a Coruña (UDC), A Coruña, Spain
| | | | - Gerasimos Filippatos
- Heart Failure Unit, Attikon University Hospital, National and Kapodistrian University of Athens, Greece. School of Medicine, University of Cyprus, Nicosia, Cyprus
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK.,RCCS San Raffaele Pisana, Rome, Italy
| | - Petar Seferovic
- Serbian Academy of Sciences and Arts, Heart Failure Center, Faculty of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Stamatis Adamopoulos
- Heart Failure and Heart Transplantation Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Yaron Barac
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicolaas De Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Frigerio
- Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | | | - Israel Gotsman
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel
| | - Osnat Itzhaki Ben Zadok
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Piotr Ponikowski
- Centre for Heart Diseases, University Hospital, Wroclaw, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Luciano Potena
- Heart and Lung Transplant Program, Bologna University Hospital, Bologna, Italy
| | - Arsen Ristic
- Department of Cardiology of the Clinical Center of Serbia, Belgrade University School of Medicine, Belgrade, Serbia
| | - Tiny Jaarsma
- Department of Nursing, Faculty of Medicine and Health Sciences, University of Linköping, Linköping, Sweden
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Abstract
Left ventricular assist devices (LVADs) are indicated in inotrope-dependent heart failure (HF) patients with pure or predominant LV dysfunction. Survival benefit is less clear in ambulatory, advanced HF. Timing is crucial: early, unnecessary exposure to the risks of surgery, and device-related complications (infections, stroke, and bleeding) should be weighed against the probability of dying or developing irreversible right ventricular and/or end-organ dysfunction while deferring implant. The interplay between LVAD and heart transplantation depends largely on donor availability and allocation rules. Postoperatively, quality of life depends on patients' expectations and is influenced by complications. Patients' preferences, prognosis, and alternative options-including palliation-should be openly discussed and reviewed before and after the operation.
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Affiliation(s)
- Maria Frigerio
- 2nd Section of Cardiology, Heart Failure and Transplant Unit, DeGasperis CardioCenter, Niguarda Great Metropolitan Hospital, Milan, Italy.
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15
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Krzelj K, Petricevic M, Gasparovic H, Biocina B, McGiffin D. Ventricular Assist Device Driveline Infections: A Systematic Review. Thorac Cardiovasc Surg 2021; 70:493-504. [PMID: 34521143 DOI: 10.1055/s-0041-1731823] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Infection is the most common complication in patients undergoing ventricular assist device (VAD) implantation. Driveline exit site (DLES) infection is the most frequent VAD infection and is a significant cause of adverse events in VAD patients, contributing to morbidity, even mortality, and repetitive hospital readmissions. There are many risk factors for driveline infection (DLI) including younger age, smaller constitution of patients, obesity, exposed velour at the DLES, longer duration of device support, lower cardiac index, higher heart failure score, DLES trauma, and comorbidities such as diabetes mellitus, chronic kidney disease, and depression. The incidence of DLI depends also on the device type. Numerous measures to prevent DLI currently exist. Some of them are proven, whereas the others remain controversial. Current recommendations on DLES care and DLI management are predominantly based on expert consensus and clinical experience of the certain centers. However, careful and uniform DLES care including obligatory driveline immobilization, previously prepared sterile dressing change kits, and continuous patient education are probably crucial for prevention of DLI. Diagnosis and treatment of DLI are often challenging because of certain immunological alterations in VAD patients and microbial biofilm formation on the driveline surface areas. Although there are many conservative and surgical methods described in the DLI treatment, the only possible permanent solution for DLI resolution in VAD patients is heart transplantation. This systematic review brings a comprehensive synthesis of recent data on the prevention, diagnostic workup, and conservative and surgical management of DLI in VAD patients.
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Affiliation(s)
- Kristina Krzelj
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mate Petricevic
- Division of Health Studies, Department of Cardiac Surgery, University of Split, University Hospital Center Zagreb, Zagreb, Croatia
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - David McGiffin
- Department of Cardiothoracic Surgery and Transplantation, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Clayton, Victoria, Australia
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16
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Koken ZO, Yalcin YC, van Netten D, de Bakker CC, van der Graaf M, Kervan U, Verkaik NJ, Caliskan K. Driveline exit-site care protocols in patients with left ventricular assist devices: a systematic review. Eur J Cardiothorac Surg 2021; 60:506-515. [PMID: 33963835 PMCID: PMC8434872 DOI: 10.1093/ejcts/ezab195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Driveline infections continue to be a significant complication following left ventricular assist device (LVAD) implantation. Driveline exit-site care is crucial for the prevention of infections; however, there are no uniform guidelines. The goal of this study was to provide an overview of the currently published driveline exit-site care protocols in patients with LVAD. METHODS A systematic literature review was performed. Studies before 15 December 2020 were included if the number of driveline infections was a primary outcome and the driveline exit-site care protocol was explained. RESULTS Eleven articles were included in the systematic review, including 1602 patients with LVADs. The median of the frequency of driveline infections in the articles was 13.8% with a range of 0–52.6%. There was a marked variability in the methods of care of driveline exit sites, without a standardized driveline dressing technique in patients with LVADs. The frequency of driveline infections was 6–7.5% in studies using a dressing kit that included chlorhexidine, a silver-based dressing and an anchoring device. Furthermore, there was variability in the anchoring devices and the frequency of dressing changes, which varied from daily to weekly. No specific anchoring device or change frequency was found to be superior. CONCLUSIONS Based on this systematic review, driveline exit care protocols that included chlorhexidine, a silver-based dressing, the use of an anchoring device and dressing kits might be best in reducing driveline infection rates. However, prospective studies with larger cohorts are needed to establish the optimal protocol for driveline exit-site care.
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Affiliation(s)
- Zeliha Ozdemir Koken
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Erasmus University Medical Center, Rotterdam, Netherlands.,Surgical Nursing Department, Faculty of Nursing, Hacettepe University, Ankara, Turkey
| | - Yunus C Yalcin
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Cardio-thoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Diana van Netten
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Chantal C de Bakker
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maaike van der Graaf
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Umit Kervan
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nelianne J Verkaik
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Erasmus University Medical Center, Rotterdam, Netherlands
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17
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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.
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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
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18
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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.
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19
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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]
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20
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Stroke Risk Following Infection in Patients with Continuous-Flow Left Ventricular Assist Device. Neurocrit Care 2020; 31:72-80. [PMID: 30644037 DOI: 10.1007/s12028-018-0662-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Infection has been associated with stroke in patients with left ventricular assist devices (LVAD); however, little data exist on the timing, type and mortality impact of infection-related stroke. METHODS Prospectively collected data of HeartMate II (N = 332) and HeartWare (N = 70) LVAD patients from a single center were reviewed. Only strokes (ischemic or hemorrhagic) that occurred within 6 weeks following a LVAD infection were considered in analyses. The association between LVAD infections (wound, pump pocket, driveline and/or bloodstream infection [BSI]), specific pathogens and ischemic and hemorrhagic strokes was evaluated using multivariable logistic regression analysis. The impact of infection-related stroke on cumulative survival was assessed using Kaplan-Meier analysis. RESULTS Of 402 patients, LVAD infection occurred in 158 (39%) including BSI in 107 (27%), driveline infection in 67 (17%), wound infection in 31 (8%) and pump pocket infection in 24 (6%). LVAD infection-related stroke occurred in 20/158 (13%) patients in a median of 4 days (0-36 days) from documented infection. In multivariable analysis, ischemic stroke was associated with wound infection (aOR 9.0, 95% CI 2.4-34.0, P = 0.001) and BSI (aOR 7.7, 95% CI 0.9-66.0, P = 0.064), and hemorrhagic stroke was associated with BSI in 100% of cases (P = 0.01). There was no association with driveline or pump pocket infection. The cumulative survival rate among patients with infection-related stroke was significantly lower compared to those with LVAD infection but no stroke (log-rank P < 0.001). There was a trend toward shorter stroke-free survival among patients with LVAD infection. CONCLUSIONS LVAD infections, particularly BSI, are significantly associated with stroke, and infection-related stroke conferred significantly lower cumulative survival.
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21
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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.
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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
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22
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DeFilippis EM, Nakagawa S, Maurer MS, Topkara VK. Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions. J Am Geriatr Soc 2019; 67:2410-2419. [DOI: 10.1111/jgs.16105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Ersilia M. DeFilippis
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Shunichi Nakagawa
- Adult Palliative Care, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
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23
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Evaluation of 30 Day Readmissions After Index Ventricular Assist Device Implantation in the United States. ASAIO J 2019; 65:601-604. [DOI: 10.1097/mat.0000000000000889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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24
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Tattevin P, Flécher E, Auffret V, Leclercq C, Boulé S, Vincentelli A, Dambrin C, Delmas C, Barandon L, Veniard V, Kindo M, Cardi T, Gaudard P, Rouvière P, Sénage T, Jacob N, Defaye P, Chavanon O, Verdonk C, Para M, Pelcé E, Gariboldi V, Pozzi M, Grinberg D, Savouré A, Litzler PY, Babatasi G, Belin A, Garnier F, Bielefeld M, Hamon D, Lellouche N, Bernard L, Bourguignon T, Eschalier R, D'Ostrevy N, Jouan J, Varlet E, Vanhuyse F, Blangy H, Martins RP, Galand V. Risk factors and prognostic impact of left ventricular assist device-associated infections. Am Heart J 2019; 214:69-76. [PMID: 31174053 DOI: 10.1016/j.ahj.2019.04.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/26/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Left ventricular assist device (LVAD)-associated infections may be life-threatening and impact patients' outcome. We aimed to identify the characteristics, risk factors, and prognosis of LVAD-associated infections. METHODS Patients included in the ASSIST-ICD study (19 centers) were enrolled. The main outcome was the occurrence of LVAD-associated infection (driveline infection, pocket infection, or pump/cannula infection) during follow-up. RESULTS Of the 652 patients enrolled, 201 (30.1%) presented a total of 248 LVAD infections diagnosed 6.5 months after implantation, including 171 (26.2%), 51 (7.8%), and 26 (4.0%) percutaneous driveline infection, pocket infection, or pump/cannula infection, respectively. Patients with infections were aged 58.7 years, and most received HeartMate II (82.1%) or HeartWare (13.4%). Most patients (62%) had implantable cardioverter-defibrillators (ICDs) before LVAD, and 104 (16.0%) had ICD implantation, extraction, or replacement after the LVAD surgery. Main pathogens found among the 248 infections were Staphylococcus aureus (n = 113' 45.4%), Enterobacteriaceae (n = 61; 24.6%), Pseudomonas aeruginosa (n = 34; 13.7%), coagulase-negative staphylococci (n = 13; 5.2%), and Candida species (n = 13; 5.2%). In multivariable analysis, HeartMate II (subhazard ratio, 1.56; 95% CI, 1.03 to 2.36; P = .031) and ICD-related procedures post-LVAD (subhazard ratio, 1.43; 95% CI, 1.03-1.98; P = .031) were significantly associated with LVAD infections. Infections had no detrimental impact on survival. CONCLUSIONS Left ventricular assist device-associated infections affect one-third of LVAD recipients, mostly related to skin pathogens and gram-negative bacilli, with increased risk with HeartMate II as compared with HeartWare, and in patients who required ICD-related procedures post-LVAD. This is a plea to better select patients needing ICD implantation/replacement after LVAD implantation.
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Affiliation(s)
- Pierre Tattevin
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Erwan Flécher
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Vincent Auffret
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | | | - Stéphane Boulé
- CHU Lille, Institut Coeur-Poumons, Cardiac Intensive Care Unit, Department of Cardiology, Department of Cardiac Surgery, Lille, France
| | - André Vincentelli
- CHU Lille, Institut Coeur-Poumons, Cardiac Intensive Care Unit, Department of Cardiology, Department of Cardiac Surgery, Lille, France
| | - Camille Dambrin
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Clément Delmas
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Laurent Barandon
- Hôpital Cardiologique du Haut-Lévêque, Université Bordeaux II, Bordeaux, France
| | - Vincent Veniard
- Hôpital Cardiologique du Haut-Lévêque, Université Bordeaux II, Bordeaux, France
| | - Michel Kindo
- Département de chirurgie cardiovasculaire, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Thomas Cardi
- Département de chirurgie cardiovasculaire, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Philippe Gaudard
- Department of Cardiac Surgery, Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, Montpellier, France
| | - Philippe Rouvière
- Department of Cardiac Surgery, Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, Montpellier, France
| | - Thomas Sénage
- Department of Cardiology and Heart Transplantation Unit, CHU, Nantes, France
| | - Nicolas Jacob
- Department of Cardiology and Heart Transplantation Unit, CHU, Nantes, France
| | - Pascal Defaye
- Department of Cardiology and Cardiovascular Surgery, CHU Michallon, Grenoble, France
| | - Olivier Chavanon
- Department of Cardiology and Cardiovascular Surgery, CHU Michallon, Grenoble, France
| | - Constance Verdonk
- Department of Cardiology and cardiac surgery, Bichat-Hospital, Paris, France
| | - Marylou Para
- Department of Cardiology and cardiac surgery, Bichat-Hospital, Paris, France
| | - Edeline Pelcé
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Vlad Gariboldi
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Daniel Grinberg
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Arnaud Savouré
- Department of Cardiology and Cardiovascular Surgery, Hospital Charles Nicolle, Rouen, France
| | - Pierre-Yves Litzler
- Department of Cardiology and Cardiovascular Surgery, Hospital Charles Nicolle, Rouen, France
| | - Gerard Babatasi
- Department of Cardiology and Cardiac Surgery, University of Caen and University Hospital of Caen, France
| | - Annette Belin
- Department of Cardiology and Cardiac Surgery, University of Caen and University Hospital of Caen, France
| | - Fabien Garnier
- Department of Cardiology and cardiac surgery, University Hospital, Dijon, France
| | - Marie Bielefeld
- Department of Cardiology and cardiac surgery, University Hospital, Dijon, France
| | - David Hamon
- Department of Cardiology and Cardiac Surgery, AP-HP CHU Henri Mondor, Créteil, France
| | - Nicolas Lellouche
- Department of Cardiology and Cardiac Surgery, AP-HP CHU Henri Mondor, Créteil, France
| | - Louis Bernard
- Department of Cardiology and Cardiac Surgery, Tours University Hospital, Tours, France
| | - Thierry Bourguignon
- Department of Cardiology and Cardiac Surgery, Tours University Hospital, Tours, France
| | - Romain Eschalier
- CHU Clermont-Ferrand, Cardiology Department, Clermont-Ferrand, France
| | - Nicolas D'Ostrevy
- CHU Clermont-Ferrand, Cardiology Department, Clermont-Ferrand, France
| | - Jérôme Jouan
- Cardiology Department, European Georges Pompidou Hospital, Paris, France
| | - Emilie Varlet
- Cardiology Department, European Georges Pompidou Hospital, Paris, France
| | - Fabrice Vanhuyse
- Department of Cardiology and Cardiac Surgery, CHU de Nancy, Hopital de Brabois, Nancy, France
| | - Hugues Blangy
- Department of Cardiology and Cardiac Surgery, CHU de Nancy, Hopital de Brabois, Nancy, France
| | | | - Vincent Galand
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France.
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25
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 239] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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26
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Wilcox JE, Cameron KA, Harap RS, Shanklin KL, Grady KL, Cohen ER, Abicht TO, Adler ED, Alexy T, Alonso W, Beckman J, Bjelkengren J, Cagliostro B, Cogswell R, Colombo PC, Cotts W, Haglund NA, Haverstick S, Kiernan MS, Lampert B, LeMond LM, Lee S, Lerg G, Lindenfeld J, Mahr C, Meehan K, Pagani FD, Pan S, Pavone J, Um J, Yancy CW, Thinh D, Barsuk JH. Ventricular Assist Device Driveline Dressing-Change Protocols: A Need for Standardization. A Report from the SimVAD Investigators. J Card Fail 2019; 25:695-697. [PMID: 31247286 DOI: 10.1016/j.cardfail.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/05/2019] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jane E Wilcox
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL.
| | - Kenzie A Cameron
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rebecca S Harap
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL
| | - Kerry L Shanklin
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL
| | - Kathleen L Grady
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elaine R Cohen
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Eric D Adler
- University of California San Diego, San Diego, CA
| | - Tamas Alexy
- University of Minnesota Health, Minneapolis, MN
| | - Windy Alonso
- University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | | | | | | | | | | | - Brent Lampert
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | | | - Claudius Mahr
- University of Washington Medical Center, Seattle, WA
| | | | | | - Stephen Pan
- New York University Langone Health, New York City, NY
| | | | - John Um
- University of Nebraska Medical Center, Omaha, NE
| | - Clyde W Yancy
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL
| | - Duc Thinh
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jeffrey H Barsuk
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL
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27
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VAD infection during bridge-to-transplant, unique aspects of treatment and prevention. Curr Opin Organ Transplant 2019; 23:400-406. [PMID: 29979263 DOI: 10.1097/mot.0000000000000548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW VAD infections remain a frequent complication of VAD care and can markedly affect patient management before and after transplantation. This review highlights the standard-of-care approaches offered by recent guidelines as well as published data that may improve the care for patients with these challenging and often persistent infections. RECENT FINDINGS Prevention and management of VAD infections has become more standardized with updated consensus guidelines published in 2017. Unfortunately, advanced devices have not markedly affected the incidence of VAD infection. Efforts to improve, yet streamline, the prevention of VAD-specific infections are ongoing. However, the data provided in the best of recent publications are rarely effectively comparative. Granular data on management strategies are limited to a few studies. Nevertheless, several publications provide more detailed posttransplant outcomes for patients with pretransplant VAD infections and demonstrate overall excellent posttransplant survival. SUMMARY Prevention and management of VAD-specific and VAD-related infections are the ongoing work of all VAD programs. Consensus guidelines are a marker of progress for this field. Despite very good posttransplant outcomes for these patients, more granular data are required to understand how such patients arrive successfully to transplantation and how their posttransplant course is affected.
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28
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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.
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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
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29
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Hamed S, Schmack B, Mueller F, Ehlermann P, Hittmann D, Ruhparwar A, Katus HA, Raake PW, Kreusser MM. Implementation of an intensified outpatient follow-up protocol improves outcomes in patients with ventricular assist devices. Clin Res Cardiol 2019; 108:1197-1207. [DOI: 10.1007/s00392-019-01451-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
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30
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Driveline Site Is Not a Predictor of Infection After Ventricular Assist Device Implantation. ASAIO J 2019; 64:616-622. [PMID: 29035899 DOI: 10.1097/mat.0000000000000690] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term ventricular assist device (VAD) support. We aimed to assess whether VAD driveline exit site (DLES) (abdomen versus chest wall) is associated with DLI. All adult patients who underwent insertion of a HeartWare HVAD or HeartMate II (HMII) between 2009 and 2016 were included. Driveline infection was defined as clinical evidence of DLI accompanied by a positive bacterial swab and need for antibiotics. Competing risks analysis was used to assess the association between patient characteristics and DLI. Ninety-two devices (59 HMII) were implanted in 85 patients (72 men; median age 57.4 years) for bridge to transplant or destination therapy. VAD DLES was chest in 28 (30.4%) devices. Median time on VAD support was 347.5 days (IQR 145.5, 757.5), with 28 transplants and 29 deaths (27 on device). DLI occurred in 24 patients (25 devices) at a median of 140 days (IQR 67, 314) from implant. Staphylococcus aureus accounted for 15 infections (60%). Freedom from infection was 72.8% (95% confidence interval [CI] 53.1-78.0%) at 1 year and 41.9% (95% CI 21.1-61.5%) at 3 years. In competing risks regression, abdominal DLES was not predictive of DLI (hazard ratio, HR 1.65 [95% CI 0.63, 4.29]), but body mass index (BMI) >30 kg/m was (HR 2.72 [95% CI 1.25, 5.92]). In conclusion, risk of DLI is high among patients on long-term VAD support, and a nonabdominal DLES does not reduce this risk. The only predictor of DLI in this series was an elevated BMI.
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31
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Jorde UP, Shah AM, Sims DB, Madan S, Siddiqi N, Luke A, Saeed O, Patel SR, Murthy S, Shin J, Oviedo J, Watts S, Jakobleff W, Forest S, Vukelic S, Belov D, Puius Y, Minamoto G, Muggia V, Carlese A, Leung S, Rahmanian M, Leff J, Goldstein D. Continuous-Flow Left Ventricular Assist Device Survival Improves With Multidisciplinary Approach. Ann Thorac Surg 2019; 108:508-516. [PMID: 30853587 DOI: 10.1016/j.athoracsur.2019.01.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 01/14/2019] [Accepted: 01/21/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices have revolutionized the management of advanced heart failure. Device complications continue to limit survival, but enhanced management strategies have shown promise. This study compared outcomes for HeartMate II recipients before and after implementation of a multidisciplinary continuous support heart team (HTMCS) strategy. METHODS Between January 2012 and December 2016, 124 consecutive patients underwent primary HeartMate II implantation at our institution. In January 2015, we instituted a HTMCS approach consisting of (1) daily simultaneous cardiology/cardiac surgery/critical care/pharmacy/coordinator rounds, (2) pharmacist-directed anticoagulation, (3) speed optimization echocardiogram before discharge, (4) comprehensive device thrombosis screening and early intervention, (5) blood pressure clinic with pulsatility-adjusted goals, (6) early follow-up after discharge and individual long-term coordinator/cardiologist assignment, and (7) systematic basic/advanced/expert training and credentialing of ancillary in-hospital providers. All patients completed 1-year of follow-up. RESULTS Demographic characteristics for pre-HTMCS (n = 71) and HTMCS (n = 53) groups, including age (55.8 ± 12.1 versus 52.5 ± 14.1 years, p = not significant), percentage of men (77.5% versus 71.7%, p = not significant), and Interagency Registry for Mechanically Assisted Circulatory Support class 3 (84.5% versus 83.0%, p = not significant), were comparable. One-year survival was 74.6% versus 100% for the pre-HTMCS and HTMCS groups, respectively (p = 0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% versus 84.9% for the pre-HTMCS and HTMCS groups, respectively (p = 0.059). Event per patient-year rates for disabling stroke (0.15 versus 0, p = 0.019), gastrointestinal bleeding (0.87 versus 0.51, p = 0.11), and driveline infection (0.24 versus 0.10, p = 0.18) were lower for the HTMCS group, whereas pump thrombosis requiring device exchange was higher (0.09 versus 0.18, p = 0.14). CONCLUSIONS Implementing a comprehensive multidisciplinary approach substantially improved outcomes for recipients of continuous-flow left ventricular assist devices.
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Affiliation(s)
- Ulrich P Jorde
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York.
| | - Aman M Shah
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Daniel B Sims
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Shivank Madan
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Nida Siddiqi
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Anne Luke
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Omar Saeed
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Snehal R Patel
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Sandhya Murthy
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Jooyoung Shin
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Johanna Oviedo
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Sade Watts
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - William Jakobleff
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Stephen Forest
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Sasa Vukelic
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Dimitri Belov
- Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Yoram Puius
- Department of Internal Medicine, Division of Infectious Disease, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Grace Minamoto
- Department of Internal Medicine, Division of Infectious Disease, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Victoria Muggia
- Department of Internal Medicine, Division of Infectious Disease, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Anthony Carlese
- Department of Internal Medicine, Division of Critical Care Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Sharon Leung
- Department of Internal Medicine, Division of Critical Care Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Marjan Rahmanian
- Department of Internal Medicine, Division of Critical Care Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Jonathan Leff
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Daniel Goldstein
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
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Qu Y, McGiffin D, Kure C, Ozcelik B, Fraser J, Thissen H, Peleg AY. Biofilm formation and migration on ventricular assist device drivelines. J Thorac Cardiovasc Surg 2019; 159:491-502.e2. [PMID: 30955967 DOI: 10.1016/j.jtcvs.2019.02.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Driveline infections remain an important complication of ventricular assist device therapy, with biofilm formation being a major contributor. This study aimed to elucidate factors that govern biofilm formation and migration on clinically relevant ventricular assist device drivelines. METHODS Experimental analyses were performed on HeartWare HVAD (HeartWare International Inc, Framingham, Mass) drivelines to assess surface chemistry and biofilm formation. To mimic the driveline exit site, a drip-flow biofilm reactor assay was used. To mimic a subcutaneous tissue environment, a tunnel-based interstitial biofilm assay was developed. Clinical HVAD drivelines explanted at the time of cardiac transplantation were also examined by scanning electron microscopy. RESULTS Common causative pathogens of driveline infections were able to adhere to the smooth and velour sections of the HVAD driveline and formed robust biofilms in the drip-flow biofilm reactor; however, Pseudomonas aeruginosa and Candida albicans had greater biomass. Biofilm migration within the interstitial driveline tunnel was evident for Staphylococcus epidermidis, Staphylococcus aureus, and C albicans, but not P aeruginosa. Biofilm formation by staphylococci was 500 to 10,000 times higher in the tunnel-based model compared with our exit site model. The 3-dimensional structure of the driveline velour and the use of silicone adhesive in driveline manufacturing were found to promote biofilm growth, and explanted patient drivelines demonstrated inadequate tissue in-growth along the entire velour with micro-gaps between velour fibers. CONCLUSIONS This work highlights the predilection of pathogens to different parts of the driveline, the importance of the subcutaneous tunnel to biofilm formation and migration, and the presence of micro-gaps in clinical drivelines that could facilitate invasive driveline infections.
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Affiliation(s)
- Yue Qu
- Infection and Immunity Program, Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, Australia; Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred and Monash University, Melbourne, Australia
| | - Christina Kure
- Department of Cardiothoracic Surgery, The Alfred and Monash University, Melbourne, Australia
| | | | - John Fraser
- Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, Australia
| | | | - Anton Y Peleg
- Infection and Immunity Program, Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, Australia; Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.
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Pavlovic NV, Randell T, Madeira T, Hsu S, Zinoviev R, Abshire M. Risk of left ventricular assist device driveline infection: A systematic literature review. Heart Lung 2018; 48:90-104. [PMID: 30573195 DOI: 10.1016/j.hrtlng.2018.11.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) improve quality of life in end-stage heart failure but can cause serious complications such as infections with driveline infection causing significant morbidity and mortality. OBJECTIVES The purpose of this systematic literature review is to synthesize the literature to determine variables associated with driveline infection and seek opportunities to improve nursing management of LVAD drivelines. METHODS A systematic literature review was performed. The evidence was synthesized using the Johns Hopkins Nursing Evidence-Based Practice tools and the Chain of Infection epidemiological framework. RESULTS Thirty-four studies focused on vulnerable host, portal of entry, and causative organism aspects of the Chain of Infection. Increased BMI, younger age, exposed driveline velour showed increased risk of infection and driveline dressing protocol change showed lower risk of infection. CONCLUSIONS Although some risk factors for infection were identified, evidence is still limited. Nurses are uniquely positioned to improve driveline management, disrupting the chain of infection.
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Affiliation(s)
| | | | - Tim Madeira
- The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Steven Hsu
- The Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
Surgical maneuvers for implantation of a continuous-flow ventricular assist device are revolutionary concepts that have been associated with a reduction in pump-related complications. With the advancement of technology, surgical implant strategy continues to evolve, incorporating less-invasive approaches into the armamentarium of the experienced surgeon.
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Affiliation(s)
- Colleen Pietras
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 6 Silverstein, Philadelphia, PA 19104, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 6 Silverstein, Philadelphia, PA 19104, USA.
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Driveline angle is crucial for preventing driveline infection in patients with HeartMate II device. J Artif Organs 2018; 22:37-43. [DOI: 10.1007/s10047-018-1074-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/02/2018] [Indexed: 12/20/2022]
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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.
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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.
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Wert L, Hanke JS, Dogan G, Ricklefs M, Fleißner F, Chatterjee A, Feldmann C, Haverich A, Schmitto JD. Reduction of driveline infections through doubled driveline tunneling of left ventricular assist devices-5-year follow-up. J Thorac Dis 2018; 10:S1703-S1710. [PMID: 30034842 DOI: 10.21037/jtd.2018.03.127] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Driveline infection (DLI) is one of the leading causes for unplanned re-admissions of patients undergoing therapy with left ventricular assist devices (LVAD). In previous studies our group was able to show that a double tunneling implantation technique could significantly reduce infection rates one year after implantation. We now report the results of the five-year-follow up of patients receiving the double tunneling technique. Methods We retrospectively analyzed patients receiving LVAD therapy with the HeartWare ventricular assist device (HVAD) (Medtronic, Minnesota, MN, USA) LVAD. For 36 patients (group 1) the driveline was tunneled via a conventional technique. In the remaining 33 patients (group 2) the drivelines were implanted by means of a double tunneling technique. The double tunnel driveline technique involved placement of the driveline in the sheath of the rectus muscle in the umbilical direction and then subcutaneously to the left (alternatively right) upper quadrant. We retrospectively compared both groups. Primary outcome parameters were infection rate and mortality. Results Five years after LVAD implantation the DLI rate of patients operated by a double tunneling technique was significantly lower than in the conventional technique group [61% (n=22) group 1 vs. 30% (n=10) group 2, P=0.004]. The 5-year mortality was lower in group 2 [42% (n=15) group 1 vs. 27% (n=9) group 2] but did not achieve statistical significance (P=0.10). The days of LVAD support between the two groups were comparable (1,275.56±885.89 group 1 vs. 1,321.94±711.37 group 2). The tunnel technique itself showed to be strongly associated with the occurrence of DLI. Other elevated variables are liver disease and dilated cardiomyopathy as primary disease. Conclusions Double tunneling technique for driveline implantation leads to significantly lowered infection rates after 5 years of LVAD therapy and it is associated with a lower mortality.
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Affiliation(s)
- Leonhard Wert
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleißner
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Hanke JS, Dogan G, Wert L, Ricklefs M, Heimeshoff J, Chatterjee A, Feldmann C, Haverich A, Schmitto JD. Left ventricular assist device exchange for the treatment of HeartMate II pump thrombosis. J Thorac Dis 2018; 10:S1728-S1736. [PMID: 30034845 DOI: 10.21037/jtd.2018.01.115] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Pump thrombosis is the most severe and acute complication of left ventricular assist device (LVAD) therapy and treatment remains challenging. Whilst lysis therapy is often not successful, the exchange of the occluded LVAD is currently the most applied therapeutic treatment for this event. With this study we examine the effects of minimal-invasive LVAD exchange on the rate re-thrombosis and outcomes as well as adverse events in the study group. Methods Between February 2004 and December 2015 more than 600 LVADs were implanted at our institution. We retrospectively studied a patient cohort of 41 patients who underwent LVAD exchange because of pump thrombosis at a single institution. Outcomes, rates of re-thrombosis and adverse events were analyzed. Results Between February 2004 and December 2015, 87 exchanges of LVADs were performed at a single center. In 41 cases pump thrombosis was the reason for LVAD exchange. A total of 28 patient years (10,276 days) were analyzed. Average ICU stay was 15.8±20.4 days and average in-hospital stay 38.1±37.3 days after LVAD exchange. After thirty days the survival rate was 80.5%, 75.6% after 6 months and 70.7% one year after LVAD exchange. Out of the study cohort, three patients have successfully undergone heart transplantation. Twelve patients suffered a stroke postoperatively (29%). Twelve patients needed postoperative dialysis (29%). No technical complications of the VAD were recorded in the study group. Two patients underwent successful LVAD explantation due to myocardial recovery. One year after LVAD exchange, 14 patients underwent re-exchange due to pump thrombosis (34%). Eight patients suffered from a LVAD related infection out of which two patients were treated by pump exchange. A total of 12 patients died during the complete one year follow up of this study (29%). Four patients died in the second, two in the third and one in the fourth year after LVAD exchange. The remaining 17 patients are still ongoing on the device.Conclusions: It is generally feasible to treat pump thrombosis via LVAD exchange. Yet, the exchange procedure is not without risk and the risk of re-thrombosis (34%), stroke (29%), postoperative dialysis (29%) and perioperative complications remains high.
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Affiliation(s)
- Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Leonard Wert
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Heimeshoff
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Controversies and Challenges of Ventricular Assist Device Therapy. Am J Cardiol 2018; 121:1219-1224. [PMID: 29576232 DOI: 10.1016/j.amjcard.2018.01.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 11/23/2022]
Abstract
Left ventricular assist device (LVAD) therapy has emerged as an increasingly vital facet of the treatment algorithm for advanced heart failure. Growing experience with LVAD support has led to substantial improvements in outcomes, with 1-year survival rates approaching that of cardiac transplantation. These therapeutic refinements have engendered growing interests in the potential for expanding the clinical indications for LVAD therapy to patients with less advanced heart failure. The primary obstacles to this evolution of care center largely on the prevention and/or management of the adverse events associated with LVAD therapy along with patient preference. Many programs also face the mounting difficulty of balancing quality outcomes with the increased volume of implants. During the recently assembled Users Meeting organized by St. Jude Medical, heart failure clinicians from nearly 50 LVAD implanting centers discussed these and other challenges and controversies impacting the field. The present review summarizes the key insights gleaned from this meeting.
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Özdemir Z, Şenol Çelik S. Wound care of the driveline exit site in patients with a ventricular assist device: A systematic review. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2018; 26:328-335. [PMID: 32082759 PMCID: PMC7024132 DOI: 10.5606/tgkdc.dergisi.2018.14982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 02/06/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study aims to systematically define and analyze the studies on driveline exit site care methods for patients with a ventricular assist device. METHODS The studies related to driveline exit site care of the patients with a ventricular assist device published in English and Turkish between 2008 and 2017 were reviewed from the international Science Direct, PubMed, Web of Science, Scopus, and the national databases. Of a total of 83 articles, a total of seven research articles which met the inclusion criteria were included in the study. RESULTS Findings related to the agents used in the cleaning of the driveline exit site, dressing closures, dressing change frequency, and use of driveline anchoring devices were obtained from studies included in the research. It was found that chlorhexidine solution for skin cleaning and sterile gauze sheets and transparent covering for dressing closure were the most preferred methods for the driveline exit site care. Dressing change frequency varied considerably from center to center and anchoring devices were used in all studies. CONCLUSION There is no gold standard method for the driveline exit site care of patients with a ventricular assist device and researches on the driveline exit site care seem to be limited. It is recommended that large-scale, randomized-controlled studies should be conducted which would provide a stronger proof of the driveline exit site care.
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Affiliation(s)
- Zeliha Özdemir
- Surgical Nursing Department, Hacettepe University Faculty of Nursing, Ankara, Turkey
| | - Sevilay Şenol Çelik
- Surgical Nursing Department, Hacettepe University Faculty of Nursing, Ankara, Turkey
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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
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Peberdy MA, Gluck JA, Ornato JP, Bermudez CA, Griffin RE, Kasirajan V, Kerber RE, Lewis EF, Link MS, Miller C, Teuteberg JJ, Thiagarajan R, Weiss RM, O'Neil B. Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e1115-e1134. [PMID: 28533303 DOI: 10.1161/cir.0000000000000504] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients.
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Sánchez-Enrique C, Jorde UP, González-Costello J. Trasplante cardiaco y soporte circulatorio mecánico para pacientes con insuficiencia cardiaca avanzada. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.10.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Sánchez-Enrique C, Jorde UP, González-Costello J. Heart Transplant and Mechanical Circulatory Support in Patients With Advanced Heart Failure. ACTA ACUST UNITED AC 2017; 70:371-381. [DOI: 10.1016/j.rec.2016.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 11/28/2016] [Indexed: 12/27/2022]
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Sunagawa G, Koprivanac M, Karimov JH, Moazami N, Fukamachi K. Current status of mechanical circulatory support for treatment of advanced end-stage heart failure: successes, shortcomings and needs. Expert Rev Cardiovasc Ther 2017; 15:377-387. [PMID: 28351172 DOI: 10.1080/14779072.2017.1313114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Heart failure (HF) remains a major global burden in terms of morbidity and mortality. Despite advances in pharmacological and resynchronization device therapy, many patients worsen to end-stage HF. Although the gold-standard treatment for such patients is heart transplantation, there will always be a shortage of donor hearts. Areas covered: A left ventricular assist device (LVAD) is a valuable option for these patients as a bridge measure (to recovery, to candidacy for transplant, or to transplant itself) or as destination therapy. This review describes the current indications for and complications of the most commonly implanted LVADs. In addition, we review the potential and promising new LVADs, including the HeartMate 3, MVAD, and other LVADs. Studies investigating each were identified through a combination of online database and direct extraction of studies cited in previously identified articles. Expert commentary: The goal of LVADs has been to fill the gap between patients with end-stage HF who would likely not benefit from heart transplantation and those who could benefit from a donor heart. As of now, the use of LVADs has been limited to patients with end-stage HF, but next-generation LVAD therapy may improve both survival and quality of life in less sick patients.
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Affiliation(s)
- Gengo Sunagawa
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Marijan Koprivanac
- b Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure , Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Jamshid H Karimov
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Nader Moazami
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA.,b Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure , Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Kiyotaka Fukamachi
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA
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Gustafsson F, Rogers JG. Left ventricular assist device therapy in advanced heart failure: patient selection and outcomes. Eur J Heart Fail 2017; 19:595-602. [DOI: 10.1002/ejhf.779] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/01/2017] [Accepted: 01/05/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet; Copenhagen Denmark
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Zafar F, Villa CR, Morales DL, Blume ED, Rosenthal DN, Kirklin JK, Lorts A. Does Small Size Matter With Continuous Flow Devices? JACC-HEART FAILURE 2017; 5:123-131. [DOI: 10.1016/j.jchf.2016.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/06/2016] [Accepted: 09/11/2016] [Indexed: 01/08/2023]
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Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) has become the main focus of heart replacement therapy for end stage heart failure patients. Advances in technology are moving towards miniaturization, biventricular support devices, complete internalization, improved hemocompatibility profiles, and responsiveness to cardiac loading conditions. This review will discuss the recent advances and investigational devices in MCS for advanced heart failure. RECENT FINDINGS The demand for both short-term and long-term durable devices for advanced heart failure is increasing. The current devices are still fraught with an unacceptably high incidence of gastrointestinal bleeding and thromboembolic and infectious complications. New devices are on the horizon focusing on miniaturization, versatility for biventricular support, improved hemocompatibility, use of alternate energy sources, and incorporation of continuous hemodynamic monitoring. SUMMARY The role for MCS in advanced heart replacement therapy is steadily increasing. With the advent of newer generation devices on the horizon, the potential exists for MCS to surpass heart transplantation as the primary therapy for advanced heart failure.
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Kusne S, Staley L, Arabia F. Prevention and Infection Management in Mechanical Circulatory Support Device Recipients. Clin Infect Dis 2016; 64:222-228. [PMID: 27986679 DOI: 10.1093/cid/ciw698] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 11/05/2016] [Indexed: 12/19/2022] Open
Abstract
There are currently no guidelines for the management of infection and its prevention in mechanical circulatory support (MCS) device recipients. The International Society of Heart and Lung Transplantation (ISHLT) has initiated a multidisciplinary collaboration for the creation of a consensus document to guide clinicians in infection prevention and management in MCS patients. Most medical centers use local protocols that are based on expert opinion. MCS recipients are debilitated and have some immunological dysfunction. Over the years there have been technical advancements with smaller devices and drivelines with improved durability. The pulsatile devices have been replaced with newer-generation continuous-flow devices. Patient are living longer with MCSs for bridge to transplant (BTT) and destination therapy (DT). MCS centers have improved patient management by introducing standardized driveline protocols, leading to reduced infection rates among MCS recipients.
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Affiliation(s)
| | - Linda Staley
- Cardiothoracic Surgery Division, Mayo Clinic, Phoenix, Arizona; and
| | - Francisco Arabia
- Cardiothoracic Surgery Division, Cedars-Sinai Medical Center, Los Angeles, California
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