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Fuller R, Jacobs SE. Candida Infectious Endocarditis and Implantable Cardiac Device Infections. Mycopathologia 2023; 188:893-905. [PMID: 37277679 DOI: 10.1007/s11046-023-00745-x] [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: 02/27/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
Intravascular diseases due to Candida species, including endocarditis and cardiac device-associated infections, are rare yet devastating manifestations of invasive candidiasis affecting an already vulnerable population. Despite their significant associated morbidity and mortality, limited prospective data exist to inform the optimal diagnostic and therapeutic approaches to these entities. Herein, we review the existing literature pertaining to the epidemiology, diagnosis, and management of infectious endocarditis, rhythm management device infections, and circulatory support device infections caused by Candida species and suggest areas for future research.
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Affiliation(s)
- Risa Fuller
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Samantha E Jacobs
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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Non LR, Yumul IK, Ince D. First report of Histoplasma capsulatum left ventricular assist device infection. Transpl Infect Dis 2023; 25:e14139. [PMID: 37638832 DOI: 10.1111/tid.14139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Lemuel R Non
- Department of Medicine, Division of Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ily Kristine Yumul
- Department of Medicine, Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Dilek Ince
- Department of Medicine, Division of Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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3
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Brandão SMG, Biseli B, Ayub-Ferreira SM, Strabelli TMV, Bocchi EA. Treatment of fungal infection on left ventricle assist device driveline exit site: a case report and systematic review. J Wound Care 2023; 32:cxc-cxciv. [PMID: 37703221 DOI: 10.12968/jowc.2023.32.sup9a.cxc] [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: 09/15/2023]
Abstract
OBJECTIVE The use of ventricular assist devices (VAD) is increasing; however, diagnosis and management of device complications, such as the driveline exit site (DES) being the portal of entry for fungal infection, is not well known. METHOD A systematic review involving searching PubMed (2005 to July 2020) was conducted. The case of a 43-year-old female patient who had a left VAD (LVAD) (HeartMate 3, Abbott, US) is also reported. RESULTS The patient was successfully treated with ketoconazole cream and oral fluconazole for likely superficial DES fungal infections. We included 36 studies that met our inclusion criteria; however, only one was included in our review. In the literature, five cases of DES fungal infection were reported, with Candida being the only fungal pathogen. CONCLUSION LVAD fungal infections are uncommon but can be responsible for high mortality rates, require a prolonged period of treatment, and can present a huge problem when surgical alternatives are not available. However, Candida species are most common. Fungal infections can only produce clear discharge, and so the classic definition of driveline infection based on purulent secretion can vary. Negative skin culture does not exclude the diagnosis of infection of the DES, and so empirical diagnosis may only be clinically based.
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Affiliation(s)
| | - Bruno Biseli
- Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Silvia Moreira Ayub-Ferreira
- Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Tânia Mara Varejão Strabelli
- Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Edimar Alcides Bocchi
- Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
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4
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Zhu T, Dufendach KA, Hong Y, Thoma FW, Kilic A. Infectious complications following contemporary left ventricular assist device implantation. J Card Surg 2022; 37:2297-2306. [PMID: 35502490 DOI: 10.1111/jocs.16545] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/21/2022] [Accepted: 03/10/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of this study is to evaluate the source of infectious complications following contemporary left ventricular assist device (LVAD) implantation and to determine the impact of infections on patient outcomes. METHODS All patients who underwent centrifugal LVAD implantation between 2014 and 2020 at a single center were retrospectively reviewed. Postimplant infections were categorized as VAD-specific, VAD-related, or non-VAD according to previously published definitions. Postoperative survival and freedom from readmission were assessed using Kaplan-Meier analysis. Univariable and multivariable analyses were performed to determine the risk factors for postoperative infectious complications. RESULTS A total of 212 patients underwent centrifugal LVAD implantation (70 HeartMate 3, 142 HeartWare HVAD) during the study period. One hundred and two patients (48.1%) developed an infection, including 34 VAD-specific, 11 VAD-related, and 57 non-VAD. Staphylococcus species were the most common source of postoperative infection (n = 57, 33.7%). In multivariable analysis, diabetes significantly impacted overall postoperative infection rate. At 12 and 24 months, respectively, Kaplan-Meier survival was 81.1% and 61.6% in the infection group and 83.4% and 78.1% in the noninfection group (p = 0.006). Within the total cohort, 12- and 24-month freedom from infection were 46.2% and 31.9%, respectively. Patients with infectious complication had significantly lower rate of transplantation (16.4% vs. 43.6%; p < 0.001), increased overall mortality (46.3% vs. 17.3%, p < 0.001), and increased rates of noncardiac readmission (58.2% vs. 37.3%, p = 0.007). CONCLUSIONS Infections are common following contemporary LVAD implantation and are most commonly non-VAD related. Patients with postoperative infectious complications have significantly reduced rates of transplantation, survival, and freedom from noncardiac readmission.
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Affiliation(s)
- Toby Zhu
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | - Keith A Dufendach
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | - Yeahwa Hong
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | - Floyd W Thoma
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | - Arman Kilic
- Division of Cardiac Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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5
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Fuller R, Taimur S, Baneman E. Mechanical Circulatory Support Infections in Heart Transplant Candidates. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00772-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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6
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Characteristics and Outcomes of Candidemia in Patients with Durable Left Ventricular Assist Device Support. ASAIO J 2021; 68:1044-1047. [PMID: 34967788 DOI: 10.1097/mat.0000000000001610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
There are limited data on the characteristics and clinical course of fungal infections in patients on durable left ventricular assist device (LVAD) support. We sought to further characterize the epidemiology and outcomes of LVAD patients with fungemia. We performed a retrospective review of patients receiving LVAD support from January 2012 through June 2020 at a large academic institution. Among 336 patients on LVAD support, five (1.4%) were diagnosed with fungemia during the study period. Three patients had diabetes with mean hemoglobin A1c 7.1% (R 6.6, 7.4). Fever and leukocytosis (mean white blood count 17.0 thousand/µL [R 12.5, 29.9]) were the most common symptoms. Fungemia was diagnosed early after LVAD implantation (mean 14.4 support days [R 2, 19]). All patients were infected with Candida species, and four isolates were susceptible to fluconazole. Central nervous system outcomes included an ischemic stroke, subarachnoid hemorrhage, and malignant hemorrhagic stroke. Two patients were successfully transplanted, and two patients on destination therapy remain on suppressive fluconazole. In conclusion, fungemia is a rare and severe complication in LVAD patients occurring early postimplant.
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Lambadaris M, Vishram-Nielsen JKK, Amadio JM, Husain S, Rao V, Billia F, Alba AC. Association between continuous-flow left ventricular assist device infections requiring long-term antibiotic use and post-heart transplant morbidity and mortality. J Card Surg 2021; 37:96-104. [PMID: 34651943 DOI: 10.1111/jocs.16073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM OF STUDY There exists controversy regarding the impact of infection in patients with a left ventricular assist device (LVAD) on post-heart transplant outcomes. This study evaluated the association between infections during LVAD support and the risk of early and late post-heart transplant infection, rejection, and mortality in transplant recipients bridged with an LVAD. METHODS This is a single-center retrospective observational cohort study of consecutive adults supported with a continuous flow LVAD undergoing heart transplant between 2006 and 2019 at the Toronto General Hospital. The grade of LVAD infection was classified as per International Society of Heart and Lung Transplantation guidelines. Patients were divided into three groups: (1) patients with LVAD-specific infection confirmed with positive cultures requiring long-term antibiotic use until the time of transplant; (2) patients with any type of infection in whom antibiotics were stopped at least 1 month before transplant; (3) patients without any infections between LVAD implant and transplant. Logistic regression and Cox proportional hazard models were used to evaluate early- and late-post transplant outcomes, respectively. RESULTS We included 75 LVAD recipients: 16 (21%) patients had a chronic LVAD-related infection on suppressive antibiotics, 30 (40%) had a resolved infection, and 29 (39%) had no infections. During a median post-transplant follow-up time of 4 (2 to 7) years, 65 (87%) patients developed infections, 43 (64%) rejections, and 17 (23%) deaths. Both short- and long-term risks of infection, rejection, and mortality did not differ significantly among the groups. CONCLUSION LVAD patients with infections did not have a significantly higher risk of infection, rejection, or mortality at any time point after transplant.
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Affiliation(s)
- Maria Lambadaris
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Julie K K Vishram-Nielsen
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Jennifer M Amadio
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Vivek Rao
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Filio Billia
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Ted Rogers Center for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Ana C Alba
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Ted Rogers Center for Heart Research, University Health Network, Toronto, Ontario, Canada
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Abstract
Invasive candidiasis (IC) is a collective term that refers to a group of infectious syndromes caused by a variety of species of Candida, 6 of which cause most cases globally. Candidemia is probably the most commonly recognized syndrome associated with IC; however, Candida can cause invasive infection of any organ, especially visceral organs, vasculature, bones and joints, the eyes and central nervous system. Targeted prevention and empirical therapy are important interventions for patients at high risk for IC, and the current approach should be based on a combination of clinical risk factors and non-culture-based diagnostics, when available.
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Affiliation(s)
- Todd P McCarty
- University of Alabama at Birmingham, Birmingham VA Medical Center, 1900 University Boulevard, THT 229, Birmingham, AL 35294, USA.
| | - Cameron M White
- University of Alabama at Birmingham, 1900 University Boulevard, THT 229, Birmingham, AL 35294, USA
| | - Peter G Pappas
- University of Alabama at Birmingham, 1900 University Boulevard, THT 229, Birmingham, AL 35294, USA
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9
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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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10
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Tan SYL, Chung SJ, Tan TE, Teo L, Tan BH, Tan YE. An unusual case of Scedosporium apiospermum fungaemia in an immunocompetent patient with a left ventricular assist device and an implantable cardiac device. Access Microbiol 2020; 2:acmi000148. [PMID: 33195980 PMCID: PMC7656191 DOI: 10.1099/acmi.0.000148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/14/2020] [Indexed: 11/24/2022] Open
Abstract
Left ventricular assist device (LVAD)-related infections are a leading cause of morbidity and mortality, with fungal infections being particularly difficult to manage. We report a case of an immunocompetent 39-year-old male with an LVAD and an implantable cardiac device (ICD) who developed fatal Scedosporium apiospermum fungaemia. To the best of our knowledge, this is the first reported case of LVAD-related S. apiospermum fungaemia.
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Affiliation(s)
- Shireen Yan Ling Tan
- Department of Microbiology, Singapore General Hospital, Academia, 20 College Road, Singapore 169856, Singapore
| | - Shimin Jasmine Chung
- Department of Infectious Diseases, Singapore General Hospital, Academia, 20 College Road, Singapore 169856, Singapore
| | - Teing Ee Tan
- National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | - Louis Teo
- National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Academia, 20 College Road, Singapore 169856, Singapore
| | - Yen Ee Tan
- Department of Microbiology, Singapore General Hospital, Academia, 20 College Road, Singapore 169856, Singapore
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11
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Cutaneous Fungal Infections in Left Ventricular Assist Device Recipients. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Rahal A, Ruch Y, Meyer N, Perrier S, Minh TH, Schneider C, Lavigne T, Marguerite S, Ajob G, Cristinar M, Epailly E, Mazzucotelli JP, Kindo M. Left ventricular assist device-associated infections: incidence and risk factors. J Thorac Dis 2020; 12:2654-2662. [PMID: 32642173 PMCID: PMC7330372 DOI: 10.21037/jtd.2020.03.26] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Left ventricular assist device (LVAD)-associated infections are major complications that can lead to critical outcomes. The aims of this study were to assess the incidence of and to determine the risk factors for LVAD-associated infections. Methods We included all consecutive patients undergoing LVAD implantation between January 1, 2010, and January 1, 2019, in a single institution. Infection-related data were retrospectively collected by review of patient's medical files. LVAD-associated infections were classified into three categories: percutaneous driveline infections, pocket infections and pump and/or cannula infections. Results We enrolled 72 patients. Twenty-one (29.2%) patients presented a total of 32 LVAD-associated infections. Eight (38.1%) patients had more than one infection. Five (62.5%) pocket infections and one (50.0%) pump and/or cannula infection were preceded by a driveline infection. The median delay between the operation and LVAD-associated infection was 6.5 (1.4-12.4) months. The probability of having a LVAD-associated infection at one year after receiving an implant was 26.6% (95% CI: 17.5-40.5%). Percutaneous driveline infections represented 68.7% of all LVAD-associated infections. Staphylococcus aureus and coagulase-negative staphylococci were the predominant bacteria in LVAD-associated infections (53.1% and 15.6%, respectively). Hospital length of stay (sdHR =1.22 per 10 days; P=0.001) and postoperative hemodialysis (sdHR =0.17; P=0.004) were statistically associated with infection. Colonization with multidrug-resistant bacteria was more frequent in patients with LVAD-associated infections than in others patients (42.9% vs. 15.7%; P=0.013). Conclusions LVAD-associated infections remain an important complication and are mostly represented by percutaneous driveline infections. Gram-positive cocci are the main pathogens isolated in microbiological samples. Patients with LVAD-associated infections are more frequently colonized with multidrug-resistant bacteria.
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Affiliation(s)
- Andréa Rahal
- Equipe Opérationnelle D'Hygiène, CHU de Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Yvon Ruch
- Department of Infectious Diseases, University Hospital, Nouvel Hôpital Civil, Strasbourg, France
| | - Nicolas Meyer
- ICube, UMR7357, Université de Strasbourg, Strasbourg, France
| | - Stéphanie Perrier
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Tam Hoang Minh
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Clément Schneider
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Thierry Lavigne
- Equipe Opérationnelle D'Hygiène, CHU de Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Sandrine Marguerite
- Department of Anesthesia and Intensive Care Unit, University Hospitals of Strasbourg, Strasbourg, France
| | - Gharib Ajob
- Department of Anesthesia and Intensive Care Unit, University Hospitals of Strasbourg, Strasbourg, France
| | - Mircea Cristinar
- Department of Anesthesia and Intensive Care Unit, University Hospitals of Strasbourg, Strasbourg, France
| | - Eric Epailly
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | | | - Michel Kindo
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
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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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14
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Aspergillus flavus Left Ventricular Assist Device Driveline Exit Site Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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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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16
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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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17
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Dal Sasso E, Bagno A, Scuri STG, Gerosa G, Iop L. The Biocompatibility Challenges in the Total Artificial Heart Evolution. Annu Rev Biomed Eng 2019; 21:85-110. [PMID: 30795701 DOI: 10.1146/annurev-bioeng-060418-052432] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
There are limited therapeutic options for final treatment of end-stage heart failure. Among them, implantation of a total artificial heart (TAH) is an acceptable strategy when suitable donors are not available. TAH development began in the 1930s, followed by a dramatic evolution of the actuation mechanisms operating the mechanical pumps. Nevertheless, the performance of TAHs has not yet been optimized, mainly because of the low biocompatibility of the blood-contacting surfaces. Low hemocompatibility, calcification, and sensitivity to infections seriously affect the success of TAHs. These unsolved issues have led to the withdrawal of many prototypes during preclinical phases of testing. This review offers a comprehensive analysis of the pathophysiological events that may occur in the materials that compose TAHs developed to date. In addition, this review illustrates bioengineering strategies to prevent these events and describes the most significant steps toward the achievement of a fully biocompatible TAH.
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Affiliation(s)
- Eleonora Dal Sasso
- Cardiovascular Regenerative Medicine Group, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua and Veneto Institute of Molecular Medicine, 35128 Padua, Italy; , , .,Padua Heart Project, Division of Cardiac Surgery, University Hospital of Padua, 35128 Padua, Italy;
| | - Andrea Bagno
- Department of Industrial Engineering, University of Padua, 35128 Padua, Italy;
| | - Silvia T G Scuri
- Padua Heart Project, Division of Cardiac Surgery, University Hospital of Padua, 35128 Padua, Italy;
| | - Gino Gerosa
- Cardiovascular Regenerative Medicine Group, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua and Veneto Institute of Molecular Medicine, 35128 Padua, Italy; , , .,Padua Heart Project, Division of Cardiac Surgery, University Hospital of Padua, 35128 Padua, Italy;
| | - Laura Iop
- Cardiovascular Regenerative Medicine Group, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua and Veneto Institute of Molecular Medicine, 35128 Padua, Italy; , , .,Padua Heart Project, Division of Cardiac Surgery, University Hospital of Padua, 35128 Padua, Italy;
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Larkin EL, Dharmaiah S, Ghannoum MA. Biofilms and beyond: expanding echinocandin utility. J Antimicrob Chemother 2019; 73:i73-i81. [PMID: 29304214 DOI: 10.1093/jac/dkx451] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Echinocandins have been in use for over 15 years, starting with the first approval in 2001. Current trends, such as increasing resistance to fluconazole and shifts toward non-albicans spp. of Candida, suggest a growing role for echinocandins, as reflected by recent (2016) updates to guidelines that recommend echinocandins as first-line treatment for candidaemia. The efficacy, tolerability, and safety of echinocandins and their target site of action (1,3-β-d-glucan synthesis) have prompted research into potential new uses, such as for treatment of biofilm infections, MDR Candida auris and dermatophytes. Moreover, new mycobiome discoveries linking inflammatory bowel disease (IBD; for instance Crohn's disease) to fungi have led to preliminary but encouraging data regarding echinocandin therapy and treatment of IBD. In this article, we will review the available evidence and potential utility of echinocandins and 1,3-β-d-glucan synthesis inhibition in these areas of emerging interest.
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Affiliation(s)
- Emily L Larkin
- Center for Medical Mycology, 11100 Euclid Ave, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sharvari Dharmaiah
- Center for Medical Mycology, 11100 Euclid Ave, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Mahmoud A Ghannoum
- Center for Medical Mycology, 11100 Euclid Ave, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Hannan MM, Xie R, Cowger J, Schueler S, de By T, Dipchand AI, Chu VH, Cantor RS, Koval CE, Krabatsch T, Hayward CS, Nakatani T, Kirklin JK. Epidemiology of infection in mechanical circulatory support: A global analysis from the ISHLT Mechanically Assisted Circulatory Support Registry. J Heart Lung Transplant 2019; 38:364-373. [PMID: 30733158 DOI: 10.1016/j.healun.2019.01.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/06/2019] [Accepted: 01/09/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite advances in device technology and treatment strategies, infection remains a major cause of adverse events (AEs) in mechanical circulatory support (MCS) patients. To characterize the epidemiology of MCS infection, we examined the type, location, and timing of infection in the International Society for Heart and Lung Transplantation Registry (ISHLT) for Mechanically Assisted Circulatory Support (IMACS) over 3 years, 2013 to 2015. METHODS Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definitions were used to categorize AE infections occurring in MCS patients within IMACS. The IMACS infection variables were mapped to ISHLT definitions for infection where feasible. Three categories of MCS infection were defined as ventricular assist device (VAD) specific, VAD related, and non-VAD. RESULTS There were 10,171 patients enrolled from January 2013 through December 2015. Infection was the most common AE, with 3,788 patients (37%) experiencing ≥ 1 infection, and 6,758 AE infections reported overall. Non-VAD infection was the largest category, 4,501: 34.0% pneumonias, 30.6% non-VAD-related bloodstream infections (BSIs), 24.15% urinary tract infections (UTIs), and 10.2% gastrointestinal infections. VAD-specific infection was the second largest category, 1,756: 82.9% driveline, 12.8% pocket, and 4.3% pump/or cannula infections. VAD-related infection was the smallest category, 501: 47.5% BSIs, 47.5% mediastinitis, and 5.0% mediastinitis/pocket infections. All 3 categories were more frequently reported ≤ 3 months after implant. CONCLUSIONS Non-VAD infection, including pneumonia, BSI, UTI, and gastrointestinal infection, was the leading category of infection in MCS patients and the most frequently reported ≤ 3 months after implant. These results provide evidence to support resourcing and strengthening infection prevention strategy early after implantation in MCS.
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Affiliation(s)
- Margaret M Hannan
- Department of Clinical Microbiology, Mater Misercordiae University Hospital, University College Dublin, Dublin, Ireland.
| | - Rongbing Xie
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
| | - Jennifer Cowger
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Stephan Schueler
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Theo de By
- EUROMACS, EACTS, Windsor, United Kingdom
| | - Anne I Dipchand
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Ryan S Cantor
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
| | - Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Thomas Krabatsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - James K Kirklin
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
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21
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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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Husain S, Sole A, Alexander BD, Aslam S, Avery R, Benden C, Billaud EM, Chambers D, Danziger-Isakov L, Fedson S, Gould K, Gregson A, Grossi P, Hadjiliadis D, Hopkins P, Luong ML, Marriott DJ, Monforte V, Muñoz P, Pasqualotto AC, Roman A, Silveira FP, Teuteberg J, Weigt S, Zaas AK, Zuckerman A, Morrissey O. The 2015 International Society for Heart and Lung Transplantation Guidelines for the management of fungal infections in mechanical circulatory support and cardiothoracic organ transplant recipients: Executive summary. J Heart Lung Transplant 2016; 35:261-282. [DOI: 10.1016/j.healun.2016.01.007] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/10/2016] [Indexed: 01/10/2023] Open
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23
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Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1-50. [PMID: 26679628 PMCID: PMC4725385 DOI: 10.1093/cid/civ933] [Citation(s) in RCA: 1836] [Impact Index Per Article: 229.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor
| | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Thomas J Walsh
- Weill Cornell Medical Center and Cornell University, New York, New York
| | | | - Jack D Sobel
- Harper University Hospital and Wayne State University, Detroit, Michigan
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Abstract
Invasive candidiasis is a collective term that refers to a group of infectious syndromes caused by a variety of species of Candida, 5 of which cause most cases. Candidemia is the most commonly recognized syndrome associated with invasive candidiasis. Certain conditions may influence the likelihood for one species versus another in a specific clinical scenario, and this can have important implications for selection of antifungal therapy and the duration of treatment. Molecular diagnostic technology plays an ever-increasing role as an adjunct to traditional culture-based diagnostics, offering significant potential toward improvement in patient care.
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Affiliation(s)
- Todd P McCarty
- University of Alabama at Birmingham, 1900 University Boulevard, 229 THT, Birmingham, AL 35294-0006, USA
| | - Peter G Pappas
- University of Alabama at Birmingham, 1900 University Boulevard, 229 THT, Birmingham, AL 35294-0006, USA.
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Kornberger A, Walter V, Jaeger F, Lehnert T, Soriano M, Moritz A, Stock UA, Beiras-Fernandez A. Necrotizing pulmonary aspergillosis and ventricular assist device infection: case report and review of literature. Transpl Infect Dis 2015. [PMID: 26224318 DOI: 10.1111/tid.12427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Necrotizing pulmonary aspergillosis and Aspergillus device infection are rare and have potentially fatal complications after left ventricular assist device (LVAD) implantation. To date, few cases of patients surviving Aspergillus device infection have been published, with survival reported only after device removal. We present a patient implanted with an LVAD in whom necrotizing pulmonary aspergillosis with device involvement was successfully treated by segmentectomy and prolonged antifungal treatment without device exchange or removal. Similar cases in the literature were searched for and are discussed in view of the severity of this complication.
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Affiliation(s)
- A Kornberger
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - V Walter
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - F Jaeger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - T Lehnert
- Department of Radiology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - M Soriano
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - A Moritz
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - U A Stock
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - A Beiras-Fernandez
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
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Abstract
The role for temporary and durable mechanical circulatory support is rapidly expanding. As the use of these technologies continues to grow, the emergency physician has an increasing opportunity to participate in the advancement of these potentially life-saving technologies. This review discusses the current role of the intra-aortic balloon pump in cardiogenic shock, describes the complications and management strategies for the critically ill patient with a left ventricular assist device, and explores the emerging role of ECMO in the emergency department for patients presenting in refractory cardiogenic shock and cardiac arrest.
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Affiliation(s)
- John C Greenwood
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA.
| | - Daniel L Herr
- Critical Care Service, Cardiac Surgery ICU, Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
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Nienaber J, Wilhelm MP, Sohail MR. Current concepts in the diagnosis and management of left ventricular assist device infections. Expert Rev Anti Infect Ther 2014; 11:201-10. [DOI: 10.1586/eri.12.163] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Maly J, Szarszoi O, Netuka I, Dorazilova Z, Pirk J. Fungal infections associated with long-term mechanical circulatory support-diagnosis and management. J Card Surg 2013; 29:95-100. [PMID: 24279890 DOI: 10.1111/jocs.12258] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Left ventricular assist devices (LVADs) are increasingly used as a treatment option for advanced heart failure. Fungal infections present a serious concern given the high association with major adverse events including death in this group of patients. The objective of this review is to summarize the incidence, risk factors, method for diagnosis, complication rate, and outcomes in patients with VADs who develop fungal infections.
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Affiliation(s)
- Jiri Maly
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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29
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Martin SI. Infectious Complications of Mechanical Circulatory Support (MCS) Devices. Curr Infect Dis Rep 2013; 15:472-477. [PMID: 24078427 DOI: 10.1007/s11908-013-0366-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Left-ventricular assist devices and other forms of mechanical circulatory support are increasingly important in the routine therapy of patients with end-stage congestive heart failure. Technology may help to decrease the rate of infections associated with these devices, but with larger numbers of implants being utilized across the globe, infections overall are becoming more commonplace. Becoming familiar with appropriate techniques for prevention and with the ideal approach to diagnostic and therapeutic strategies is key to managing mechanical circulatory support infections in this unique, but growing, patient population.
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Affiliation(s)
- Stanley I Martin
- Transplant Infectious Diseases Service, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, N1135 Doan Hall, 410 W. 10th Ave., Columbus, OH, 43210, USA,
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Abstract
Left ventricular assist devices have been proven to be superior to medical therapy for advanced heart failure patients awaiting heart transplantation and viable alternatives to transplantation for destination therapy patients. Improvements in the design of ventricular assist devices have been rewarded by a decrease in adverse events and an increase in survival. Despite significant progress, even the latest generation left ventricular assist devices are burdened by a significant long-term adverse events profile that will increasingly challenge physicians as patients survive longer on implantable mechanical circulatory support. In this review, we analyze the impact of long-term adverse events on clinical outcomes in the major trials of continuous flow left ventricular assist devices. We discuss several of the more pertinent and interesting adverse events, examine their potential causes, and explore their future implications.
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Koval CE, Rakita R. Ventricular assist device related infections and solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:348-54. [PMID: 23465027 DOI: 10.1111/ajt.12126] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- C E Koval
- Department of Infectious Disease, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Cannon A, Elliott T, Ballew C, Cavey J, O'Shea G, Franzwa J, Puhlman M, Bennett J, Ryan T, Lockard K, Avrahami N, Brennan P, Kurien S, Andrus S, Dick S, Davis E. Variability in infection control measures for the percutaneous lead among programs implanting long-term ventricular assist devices in the United States. Prog Transplant 2013. [PMID: 23187051 DOI: 10.7182/pit2012612] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Ventricular assist devices (VADs) are a surgical treatment for heart failure. These devices may be implanted as a bridge to transplant or as destination therapy. After surgical recovery and education regarding device care, patients are discharged home. Meticulous care of the driveline must be taken to prevent infection and trauma of the site throughout the perioperative event and for the duration of support. Currently a standardized protocol for care of the driveline and exit site does not exist. VAD coordinators from across the country discussed the variability in care at different centers in the United States through a series of conference calls. A survey consisting of 16 questions was developed. The survey included questions on preoperative antibiotic recommendations, driveline placement and exit site suturing, frequency of dressing changes, and showering practices. VAD coordinators shared center-specific dressing protocols and any driveline success stories. This survey was sent to 73 centers; 38 centers (52%) responded. The purpose of the survey was to define current practice in order to move toward a standard of practice or protocol based on expert opinion for VAD driveline care and to assess the need for future studies.
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Affiliation(s)
- Anne Cannon
- University of Colorado Hospital, Aurora, CO, USA.
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Von Ruden SAS, Murray MA, Grice JL, Proebstle AK, Kopacek KJ. The pharmacotherapy implications of ventricular assist device in the patient with end-stage heart failure. J Pharm Pract 2012; 25:232-49. [PMID: 22392840 DOI: 10.1177/0897190011431635] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Advances in mechanical circulatory support, such as the use of ventricular assist devices (VADs), have become a means for prolonging survival in end-stage heart failure (HF). VADs decrease the symptoms of HF and improve quality of life by replacing some of the work of a failing heart. They unload the ventricle to provide improved cardiac output and end-organ perfusion, resulting in improvement in cardiorenal syndromes and New York Heart Association functional class rating. VADs are currently used asa bridge to heart transplantation, a bridge to recovery of cardiac function, or as destination therapy. Complications of VAD include bleeding, infections, arrhythmias, multiple organ failure, right ventricular failure, and neurological dysfunction. Patients with VAD have unique pharmacotherapeutic requirements in terms of anticoagulation, appropriate antibiotic selection, and continuation of HF medications. Pharmacists in acute care and community settings are well prepared to care for the patient with VAD. These patients require thorough counseling and follow-up with regard to prevention and treatment of infections, appropriate levels of anticoagulation, and maintenance of fluid balance. A basic understanding of this unique therapy can assist pharmacists in attending to the needs of patients with VAD.
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Barbone A, Malvindi PG, Sorabella RA, Cortis G, Tosi PF, Basciu A, Ferrara P, Raffa G, Citterio E, Settepani F, Ornaghi D, Tarelli G, Vitali E. 6 months of "temporary" support by Levitronix left ventricular assist device. Artif Organs 2012; 36:639-42. [PMID: 22428655 DOI: 10.1111/j.1525-1594.2011.01428.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
An otherwise healthy 47-year-old man presented to the emergency department in cardiogenic shock after suffering a massive myocardial infarction due to left main occlusion. He was initially supported by extracorporeal membrane oxygenation and subsequently was converted to paracorporeal support with a Levitronix left ventricular assist device. He experienced multiple postoperative complications including renal failure, respiratory failure, retroperitoneal hematoma requiring suspension of anticoagulation, and fungal bloodstream infection precluding transition to an implantable device. He was reconditioned and successfully underwent orthotopic heart transplant 183 days after presentation. A discussion of the relevant issues is included.
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Affiliation(s)
- Alessandro Barbone
- UO di Cardiochirurgia, Istituto Clinico Humanitas IRCCS, Rozzano, Milan, Italy.
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Califano S, Pagani FD, Malani PN. Left Ventricular Assist Device–Associated Infections. Infect Dis Clin North Am 2012; 26:77-87. [DOI: 10.1016/j.idc.2011.09.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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McKelvie RS, Moe GW, Cheung A, Costigan J, Ducharme A, Estrella-Holder E, Ezekowitz JA, Floras J, Giannetti N, Grzeslo A, Harkness K, Heckman GA, Howlett JG, Kouz S, Leblanc K, Mann E, O'Meara E, Rajda M, Rao V, Simon J, Swiggum E, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Haddad H, Isaac DL, Leblanc MH, Liu P, Sussex B, Ross HJ. The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Sleep Apnea, Renal Dysfunction, Mechanical Circulatory Support, and Palliative Care. Can J Cardiol 2011; 27:319-38. [DOI: 10.1016/j.cjca.2011.03.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022] Open
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Intermittent aortic insufficiency as an aid to diagnosing obstruction in a HeartMate II continuous-flow left ventricular assist device. ASAIO J 2011; 57:244-6. [PMID: 21252640 DOI: 10.1097/mat.0b013e318209d389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This report details two cases of left ventricular assist device (LVAD)-related fungal infection. In both cases, the infection occurred within the device and formed an obstruction resulting in intermittent variation in the output of the LVAD. This was manifested by a change in the pattern of aortic insufficiency (AI) from continuous to intermittent on transesophageal echocardiography. Recognition of this finding may allow for noninvasive diagnosis of LVAD flow obstruction.
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