Novel driveline route for prevention from driveline infection: Triple tunnel method

Current issues of destination therapy in Japan: to achieve 5-year or even longer survival

In April 2021, destination therapy (DT) was finally approved in Japan. Since DT does not aim at heart transplantation (HT), our goal is to have a patient safely remain on an implantable ventricular assist device (VAD) for the rest of his/her life. To achieve this goal, similarly to bridge-to-transplant (BTT) patients, the authors believe the following six aspects are even more crucial in DT patients: (1) to appropriately assess risks before implantation, (2) to carefully determine the ability to manage the device by multidisciplinary discussions, (3) to prevent complications by improving the quality of care, (4) to expand the number of facilities that can take care of DT patients by improving collaboration among the facilities, (5) to reduce the burden of caregivers by utilizing social resources, and (6) to establish a home palliative care system based on advance care planning. In addition, for elderly DT patients to live happy and long lives, it is essential to help them to find a purpose of life and to keep activities of daily living, such as employment, schooling, and participation in social activities, just like the general elderly population. Our goals are not only to do our best for the patients just in front of us, but also to establish a system to follow up our DT cohort, same as BTT one, by all-Japan manner. In the present review, we discuss the current state of DT in Japan and what we need to focus on to maintain or improve its long-term performance.

Perioperative interventions for the prevention of surgical wound infection in adult patients undergoing left ventricular assist devices implantation: A scoping review

BACKGROUND

Surgical wound infection is the most frequent type of care health associated infection. Lack of knowledge about the prevention of surgical wound infection in patients undergoing left ventricular assist device implantation could significantly undermine the potential benefits of surgical intervention.

OBJECTIVES

This study aimed to map the recommendations for adult patients undergoing left ventricular assist device implantation.

DESIGN

This is a scoping review, being registered in the Open Science Framework under DOI https://doi.org/10.17605/OSF.IO/Q76B3 (https://osf.io/q76b3/).

METHOD

Left ventricular assist device coordinators and nurse specialists in dermatology and stomatherapy conducted a scoping review in Scopus, The Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), limited to the period between 2015 and 2022. The results of this scoping review will be discussed and presented in separate articles. This paper will synthesize research evidence on the perioperative topic.

RESULTS

The initial searches resulted in 771 studies. Sixty nine met the eligibility criteria and were included in the scoping review. Eight articles addressing the perioperative topic that answered the question of this article were included.

CONCLUSION

Although this scoping review included heterogeneous, and scarce studies with left ventricular assist device patients. As such, there are many promising future research directions for this topic.

IMPLICATIONS FOR CLINICAL PRACTICE

Infection surveillance should be an integral part of left ventricular assist device implantation programs in health care institutions. Velvet completely buried in subcutaneous tissues reduces transmission system infection. Triple tunnel method reduces transmission system infection risk.

Mechanical circulatory support for adults in Japan: A 10-year perspective

Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid-term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2-year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long-term LVAD support have become important. Five important topics including hemocompatibility-related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia-Pacific region and beyond.

Prophylactic negative pressure wound therapy is not effective for preventing driveline infection following left ventricular assist device implantation

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.

Impact of an improved driveline management for HeartMate II and HeartMate 3 left ventricular assist devices

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%.

Decreasing driveline infections in patients supported on ventricular assist devices: a care pathway approach

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.

Driveline Features as Risk Factor for Infection in Left Ventricular Assist Devices: Meta-Analysis and Experimental Tests

Background: Risk factors for driveline infection (DLI) in patients with left ventricular assist devices are multifactorial. The aim of this study was to analyze the correlation between mechanical driveline features and DLI occurrence. Methods: A meta-analysis was conducted that included studies reporting DLI rates at 6 months after implantation of any of three contemporary devices (HVAD with Pellethane or Carbothane driveline, HeartMate II, and HeartMate 3). Further, outer driveline diameter measurements and ex-vivo experimental three-point bending and torsion tests were performed to compare the stiffness of the four different driveline types. Results: 21 studies with 5,393 patients were included in the meta-analysis. The mean weighted DLI rates ranged from 7.2% (HeartMate II) to 11.9% (HeartMate 3). The HeartMate II driveline had a significantly lower maximal bending force (Loadmax) (4.52 ± 0.19 N) compared to the Carbothane HVAD (8.50 ± 0.08 N), the HeartMate 3 (11.08 ± 0.3 N), and the Pellethane HVAD driveline (15.55 ± 0.14 N) (p < 0.001). The maximal torque (Torquemax) of the HeartMate II [41.44 (12.61) mNm] and the Carbothane HVAD driveline [46.06 (3.78) mNm] were significantly lower than Torquemax of the Pellethane HVAD [46.06 (3.78) mNm] and the HeartMate 3 [95.63 (26.60) mNm] driveline (p < 0.001). The driveline of the HeartMate 3 had the largest outer diameter [6.60 (0.58) mm]. A relationship between the mean weighted DLI rate and mechanical driveline features (Torquemax) was found, as the the HeartMate II driveline had the lowest Torquemax and lowest DLI rate, whereas the HeartMate 3 driveline had the highest Torquemax and highest DLI rate. Conclusions: Device-specific mechanical driveline features are an additional modifiable risk factor for DLI and may influence clinical outcomes of LVAD patients.

Ventricular Assist Device Driveline Infections: A Systematic Review

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.

In Full Flow: Left Ventricular Assist Device Infections in the Modern Era

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.