1
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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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2
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Imamura T. How to manage left ventricular assist device-related infection to improve clinical outcomes following heart transplantation. J Card Surg 2021; 37:705. [PMID: 34878681 DOI: 10.1111/jocs.16177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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3
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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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4
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Esquer Garrigos Z, Jandhyala D, Vijayvargiya P, Castillo Almeida NE, Gurram P, Corsini Campioli CG, Stulak JM, Rizza SA, O’Horo JC, DeSimone DC, Baddour LM, Sohail MR. Management of Bloodstream Infections in Left Ventricular Assist Device Recipients: To Suppress, or Not to Suppress? Open Forum Infect Dis 2021; 8:ofaa532. [PMID: 33447628 PMCID: PMC7794653 DOI: 10.1093/ofid/ofaa532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/23/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Ascertaining involvement of left ventricular assist device (LVAD) in a patient presenting with bloodstream infection (BSI) can be challenging, frequently leading to use of chronic antimicrobial suppressive (CAS) therapy. We aimed to assess the efficacy of CAS therapy to prevent relapse of BSI from LVAD and non-LVAD sources. METHODS We retrospectively screened adults receiving LVAD support from 2010 through 2018, to identify cases of BSI. Bloodstream infection events were classified into LVAD-related, LVAD-associated, and non-LVAD BSIs. RESULTS A total of 121 episodes of BSI were identified in 80 patients. Of these, 35 cases in the LVAD-related, 14 in the LVAD-associated, and 46 in the non-LVAD BSI groups completed the recommended initial course of therapy and were evaluated for CAS therapy. Chronic antimicrobial suppressive therapy was prescribed in most of the LVAD-related BSI cases (32 of 35, 91.4%) and 12 (37.5%) experienced relapse. Chronic antimicrobial suppressive therapy was not prescribed in a majority of non-LVAD BSI cases (33, 58.9%), and most (31, 93.9%) did not experience relapse. Chronic antimicrobial suppressive therapy was prescribed in 9 of 14 (64.2%) cases of LVAD-associated BSI and none experienced relapse. Of the 5 cases in this group that were managed without CAS, 2 had relapse. CONCLUSIONS Patients presenting with LVAD-related BSI are at high risk of relapse. Consequently, CAS therapy may be a reasonable approach in the management of these cases. In contrast, routine use of CAS therapy may be unnecessary for non-LVAD BSIs.
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Affiliation(s)
- Zerelda Esquer Garrigos
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Deeksha Jandhyala
- Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Prakhar Vijayvargiya
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Natalia E Castillo Almeida
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Pooja Gurram
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Cristina G Corsini Campioli
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Stacey A Rizza
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - John C O’Horo
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Daniel C DeSimone
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - M Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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5
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Qu Y, McGiffin D, Kure C, McLean J, Duncan C, Peleg AY. In vitro Evaluation of Medihoney Antibacterial Wound Gel as an Anti-biofilm Agent Against Ventricular Assist Device Driveline Infections. Front Microbiol 2020; 11:605608. [PMID: 33329497 PMCID: PMC7719625 DOI: 10.3389/fmicb.2020.605608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives: In adult ventricular assist device (VAD) programs in Australian hospitals, Medihoney Antibacterial Wound Gel (MAWG) is routinely used at the skin exit-site of VAD drivelines to prevent infections; however, its effectiveness remains unclear. Our aim was to assess antimicrobial activity of Medihoney wound gel, using in vitro models that mimic clinical biofilms grown at the driveline exit-site. Methods: Antimicrobial susceptibility testing of MAWG was performed for 24 clinical isolates grown under planktonic conditions, and four representative strains grown as biofilms. Different antimicrobial mechanisms of MAWG were assessed respectively for their relative contribution to its anti-biofilm activity. A colony biofilm assay and a drip-flow biofilm reactor assay mimicking the driveline exit-site environment were used to evaluate the activity of MAWG against biofilm growth at the driveline exit-site. Results: MAWG demonstrated species-specific activity against planktonic cultures [minimum inhibitory concentrations (MICs), 5-20% weight/volume (W/V) for Staphylococcus species, 20->40% (W/V) for Pseudomonas aeruginosa and Candida species]. Higher concentrations [MICs, 30->80% (W/V)] were able to inhibit biofilm growth, but failed to eradicate pre-established biofilms. The anti-biofilm properties of MAWG were multi-faceted, with the often-advertised "active" ingredient methylglyoxal (MGO) playing a less important role. The colony biofilm assay and the drip-flow biofilm reactor assay suggested that MAWG was unable to kill biofilms pre-established in a driveline exit-site environment, or effectively prevent planktonic cells from forming adherent monolayers and further developing mature biofilms. Conclusion: Our work suggests a suboptimal effectiveness of MAWG in preventing driveline infections due to biofilm development.
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Affiliation(s)
- Yue Qu
- Infection and Immunity Theme, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, Australia.,Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Christina Kure
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Janelle McLean
- Transplant Services, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Courtney Duncan
- Transplant Services, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Anton Y Peleg
- Infection and Immunity Theme, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, Australia.,Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
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6
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Infective endocarditis - A review of current therapy and future challenges. Hellenic J Cardiol 2020; 62:190-200. [PMID: 33176209 DOI: 10.1016/j.hjc.2020.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/30/2020] [Accepted: 10/12/2020] [Indexed: 11/23/2022] Open
Abstract
Etiological, microbiological and epidemiological factors changed over time, but mortality rates remain high in infective endocarditis (IE). Healthcare-associated IE is nowadays responsible for a significant proportion of cases due to increasing numbers of cardiac devices. Cardiac implantable electronic devices, transcatheter aortic valve replacement, and percutaneous valve repair are meanwhile used, especially in old and sick patients. In suspected IE modified Duke criteria, integrating clinical results, imaging, and biomarkers are traditionally applied. Newer imaging technologies such as multi-slice computed tomography, photon-emission computed tomography, and magnetic resonance imaging might add value to conventional echocardiography in diagnosis and management of IE. Treatment consists of long-term antibiotic therapy, infectiological source control and/or cardiac surgery. Recently, antibiotic parenteral outpatient regimens and partial oral treatment strategies were shown to shorten hospital stays in patients suffering from IE. However, it remains unclear how to best select patients for partial oral therapy. This review describes new trends in diagnosing, imaging, and treating IE in a changing patient collective with particular focus on patients with implantable cardiac devices.
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7
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Reduction of Postoperative Infections Through Routine Preoperative Universal Decolonization of Advanced Heart Failure Patients With Chlorhexidine and Mupirocin Before Left Ventricular Assist Device Implantation: A Single-Center Observational Study. Dimens Crit Care Nurs 2020; 39:312-320. [PMID: 33009271 DOI: 10.1097/dcc.0000000000000443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are increasingly being used in patients with advanced heart failure as bridge to transplant, bridge to decision, or destination therapy. Infections are a major complication associated with LVADs. Staphylococcus aureus is one of the common causative organisms associated with LVAD infections. Methicillin resistant staphylococcus aureus (MRSA)-colonized patients are at an increased risk for developing MRSA-associated infections. Various studies have demonstrated decolonization of skin with topical chlorhexidine and nares with 2% intranasal mupirocin ointment is effective in reducing MRSA-associated infections. OBJECTIVE The objective of this observational study was to examine the impact of a universal decolonization protocol using topical chlorhexidine and intranasal mupirocin ointment for 5 days before LVAD implantation on postoperative infections (30, 60, and 90 days) and 30-day infection-related rehospitalization. METHODS A preoperative universal decolonization with 4% chlorhexidine daily whole-body bath and 2% intranasal mupirocin ointment twice a day for 5 days was implemented for patients undergoing elective LVAD implantation. Using an observational study design, we included a convenience sample of 84 subjects who were established patients in an accredited advanced heart failure program. Thirty-seven patients served in the standard protocol group, and 47 in the universal decolonization protocol group participated in the observational study. RESULTS In the standard protocol group, there were 4 MRSA infections with none in the universal decolonization group (χ = 5.34, P = .03). In total, there were 8 surgical site infections in the standard protocol group and 1 in the universal decolonization group (χ = 5.95, P = .01). CONCLUSION A 5-day universal decolonization protocol before LVAD implantation was effective in reducing total infections as well as MRSA-specific infections.
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8
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Esquer Garrigos Z, Castillo Almeida NE, Gurram P, Vijayvargiya P, Corsini Campioli CG, Stulak JM, Rizza SA, Baddour LM, Rizwan Sohail M. Management and Outcome of Left Ventricular Assist Device Infections in Patients Undergoing Cardiac Transplantation. Open Forum Infect Dis 2020; 7:ofaa303. [PMID: 32818144 PMCID: PMC7423297 DOI: 10.1093/ofid/ofaa303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/17/2020] [Indexed: 01/20/2023] Open
Abstract
Background Postoperative management of patients undergoing cardiac transplantation with an infected left ventricular assist device (LVAD) is unclear. Methods We retrospectively screened all adults with an LVAD who underwent cardiac transplantation at our institution from 2010 through 2018. We selected all cases of LVAD-specific and LVAD-related infections who were receiving antimicrobial therapy as initial treatment course or chronic suppression at the time of cardiac transplantation. Non-LVAD infections, superficial driveline-infection, or concurrent use of right ventricular assist device or extracorporeal membrane oxygenation device were excluded. Results A total of 54 cases met study criteria with 18 of 54 (33.6%) classified as LVAD- specific or related infections and 36 of 54 (66.6%) as noninfected. cases of lvad infection had a higher median charlson comorbidity Index score at the time of transplantation compared with noninfected cases (P = .005). Of the 18 cases of infection, 13 of 18 (72.2%) were classified as LVAD-specific and 5 of 18 (27.8%) were classified as LVAD-related. Nine of 13 (69.2%) cases had proven LVAD-specific infections. Antimicrobial therapy was extended posttransplant to treat preceding LVAD-specific infection in all 9 cases (9 of 13, 69.2%) with a median duration of 14 days (interquartile range, 14–28). After LVAD removal, antimicrobial treatment was not continued for preceding LVAD-related infections. Conclusions Patients with an LVAD-specific infection were treated with 2 weeks of pathogen-directed therapy postheart transplant without any relapses. For those without LVAD-specific infection or uncomplicated LVAD-related bacteremia who had completed antimicrobial therapy pretransplant, antibiotics were discontinued after standard perioperative prophylaxis and no relapses were observed.
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Affiliation(s)
- Zerelda Esquer Garrigos
- Division of Infectious Diseases, Department of Medicine, Rochester, Minnesota, USA.,Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Pooja Gurram
- Division of Infectious Diseases, Department of Medicine, Rochester, Minnesota, USA
| | - Prakhar Vijayvargiya
- Division of Infectious Diseases, Department of Medicine, Rochester, Minnesota, USA.,Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Rochester, Minnesota, USA
| | - Stacey A Rizza
- Division of Infectious Diseases, Department of Medicine, Rochester, Minnesota, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Rochester, Minnesota, USA.,Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - M Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, Rochester, Minnesota, USA.,Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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9
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Review and reflections about pulsatile ventricular assist devices from history to future: concerning safety and low haemolysis-still needed. J Artif Organs 2020; 23:303-314. [PMID: 32367384 PMCID: PMC7666270 DOI: 10.1007/s10047-020-01170-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/13/2020] [Indexed: 11/23/2022]
Abstract
Since the first use of a ventricular assist device in 1963 many extracorporeal and implantable pulsatile blood pumps have been developed. After the invention of continuous flow blood pumps the implantable pulsatile pumps are not available anymore. The new rotary pumps spend a better quality of life because many of the patients can go home. Nevertheless, the extracorporeal pulsatile pumps have some advantages. They are low-cost systems, produce less haemolysis and heart-recovery can be tested easily. Pump failure is easy to realize because the pumps can be observed visually. Pump exchange can be done easily without any chirurgic surgery. As volume displacement pumps they can produce high blood pressure, so they are the only ones suitable for pediatric patients. Therefore, they are indispensable for clinical use today and in the future. In this work, nearly all pulsatile blood pumps used in clinical life are described.
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10
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Hubers SA, DeSimone DC, Gersh BJ, Anavekar NS. Infective Endocarditis: A Contemporary Review. Mayo Clin Proc 2020; 95:982-997. [PMID: 32299668 DOI: 10.1016/j.mayocp.2019.12.008] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/21/2019] [Accepted: 12/04/2019] [Indexed: 12/12/2022]
Abstract
Infective endocarditis (IE), initially described more than 350 years ago, involves infection of the endocardial surface of the heart. The clinical manifestations of IE can involve every organ system, and the cardiac manifestations can include valvular vegetation, abscess, periannular extension of infection, and myopericarditis. Echocardiography is crucial in the diagnosis of IE, but alternative imaging modalities are playing an increasing role in the diagnosis and management of IE. Multidisciplinary care is imperative to the management of IE, often requiring the expertise of cardiologists, cardiothoracic surgeons, infectious diseases specialists, radiologists, and neurologists. We performed a literature search of the PubMed database from January 1st, 2000, to September 30th, 2019, using the terms infective endocarditis, diagnosis, and management to find the most pertinent and highest-quality evidence. This review summarizes key aspects of IE, with a focus on emerging advances in diagnosis. We also highlight growing patient populations at risk for IE, including patients with intracardiac devices and congenital heart disease.
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Affiliation(s)
- Scott A Hubers
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN.
| | - Daniel C DeSimone
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN; Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
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11
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Au SLC, McCormick D, Lever N, Budgett D. Thermal evaluation of a hermetic transcutaneous energy transfer system to power mechanical circulatory support devices in destination therapy. Artif Organs 2020; 44:955-967. [DOI: 10.1111/aor.13679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/23/2020] [Accepted: 02/27/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Shun Long Cyril Au
- Auckland Bioengineering Institute University of Auckland Auckland New Zealand
| | - Daniel McCormick
- Auckland Bioengineering Institute University of Auckland Auckland New Zealand
| | - Nigel Lever
- Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - David Budgett
- Auckland Bioengineering Institute University of Auckland Auckland New Zealand
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12
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Anaerobic Bacteremias in Left Ventricular Assist Devices and Advanced Heart Failure. Case Rep Infect Dis 2020; 2019:7571606. [PMID: 31976097 PMCID: PMC6959158 DOI: 10.1155/2019/7571606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/27/2019] [Accepted: 12/03/2019] [Indexed: 12/02/2022] Open
Abstract
Left ventricular assisted devices (LVADs) have revolutionized the treatment of advanced heart failure, providing meaningful increases in survival, functional capacity, and quality of life. There are two categories of LVADs patients: (1) bridge-to-transplant and (2) destination therapy. Advanced heart failure and destination LVADs often carry a poor prognosis. The overall 1-year mortality rate remains as high as 30%. LVAD-specific infections, LVAD-related infections, and non-LVAD-related infections represent important emerging clinical problems in this setting. With an incidence ranging from 30 to 50%, these lead to high rates of hospitalization, morbidity, and mortality. Bacteremias caused by anaerobic pathogens in patients with LVAD are underreported. Herein, we describe the microbiological findings, treatment, and clinical outcome of four patients with LVADs and advanced heart failure with anaerobic bacteremias. Fusobacterium species was the most frequent etiological agent. Most patients had a relatively favorable short-term outcome with survival rates of 100% at 30 days and of 50% at 90 days. However, due to other multiple long-term complications, overall mortality remains at 50% during the first year and increases to 75% beyond the first year. Anaerobic bacteremia sources included the oral cavity from odontogenic infections and aspiration pneumonia. Anaerobic bacteremia constitutes an unfavorable mortality prognostic factor in patients with destination LVADs. We recommend implementing preventive strategies with a comprehensive dental care evaluation in patients with LVADs and advanced heart failure.
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13
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Lines TH, Sabato LA, Nesbitt WJ, Moretz JD, Brinkley DM, Satyanarayana G. Minimum inhibitory concentration changes in relapsed left ventricular assist device driveline infections. Int J Artif Organs 2020; 43:494-499. [PMID: 31964206 DOI: 10.1177/0391398819900188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Driveline infection is the most common infectious complication in patients with left ventricular assist devices. Minimum inhibitory concentration changes are not well described in relapsed driveline infections. This retrospective descriptive epidemiology study of patients with left ventricular assist device implantation between January 1, 2013, and August 1, 2017, who developed driveline infection with positive cultures aimed to describe minimum inhibitory concentration changes. Of the 330 patients underwent left ventricular assist device implantation, 30 (9%) met criteria for driveline infection. Median duration of follow-up was 26 months (interquartile range 16, 39) and time to first driveline infection was 171 days (interquartile range 83, 403). There were 74 driveline infections: 40 new and 34 relapsed. Staphylococcus aureus was most common in new and relapsed driveline infection. Thirteen patients comprised the 34 relapsed infections, 9 of which experienced a minimum inhibitory concentration change. Median time to first minimum inhibitory concentration change was 56 days (interquartile range 36-88), and type of minimum inhibitory concentration change was an increase in five cases, decrease in two cases, and both increase and decrease in two cases. Minimum inhibitory concentration changes did not result in resistance in S. aureus but did in Pseudomonas aeruginosa and Mycobacterium fortuitum relapsed driveline infection. Time to first relapse from initial infection was longer in those who received suppressive therapy, 60 days versus 83 days, p = 0.047. Relapsed driveline infections were most common with S. aureus. Minimum inhibitory concentration changes were quite variable and may not be the major contributor to relapsed infection in gram-positive driveline infection.
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Affiliation(s)
| | | | | | | | - D Marshall Brinkley
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gowri Satyanarayana
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Single Versus Multidrug Regimen for Surgical Infection Prophylaxis in Left Ventricular Assist Device Implantation. ASAIO J 2019; 64:735-740. [PMID: 29095735 DOI: 10.1097/mat.0000000000000710] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Infection is a serious complication of left ventricular assist device (LVAD) therapy. However, an optimal antimicrobial surgical infection prophylaxis (SIP) regimen for LVAD implantation is not well established. We retrospectively reviewed all adults who underwent continuous-flow LVAD implantation from February 2007 to March 2015 at Mayo Clinic Rochester. Left ventricular assist device infection (LVADI) was defined using criteria published by the International Society for Heart and Lung Transplant. Patients excluded from the analysis included those who did not have HeartMate II or HeartWare device, patients with incomplete documentation of SIP, and those with an actively treated infection at the time of LVAD implantation. We compared risk of LVAD-specific and LVAD-related infections and all-cause mortality between SIP regimens at postoperative day 90 and 1 year using Kaplan-Meier time-to-event analyses. During study period, 239 adults underwent continuous-flow LVAD implantation at our institution where 199 patients received single-drug and 40 received multidrug SIP regimen. Median patient age was 62 years. Left ventricular assist device infection occurred in three patients (1.5%) in the single-drug group versus two patients (5.0%) in the multidrug group at 90 days (p = 0.4). There was no difference in infection-free (p = 0.4) and overall survival (p = 0.9) between two groups at 1 year. In conclusion, there was no clear benefit of using multidrug regimen as it did not impact infection-free survival or all-cause mortality compared with single-drug regimen. Prospective clinical trials are needed to further define the optimal SIP regimen for LVAD implantation.
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15
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Left ventricular assist devices and their complications: A review for emergency clinicians. Am J Emerg Med 2019; 37:1562-1570. [PMID: 31072684 DOI: 10.1016/j.ajem.2019.04.050] [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: 03/27/2019] [Revised: 04/25/2019] [Accepted: 04/28/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION End stage heart failure is associated with high mortality. However, recent developments such as the ventricular assist device (VAD) have improved patient outcomes, with left ventricular assist devices (LVAD) most commonly implanted. OBJECTIVE This narrative review evaluates LVAD epidemiology, indications, normal function and components, and the assessment and management of complications in the emergency department (ED). DISCUSSION The LVAD is a life-saving device in patients with severe heart failure. While first generation devices provided pulsatile flow, current LVAD devices produce continuous flow. Normal components include the pump, inflow and outflow cannulas, driveline, and external controller. Complications related to the LVAD can be divided into those that are LVAD-specific and LVAD-associated, and many of these complications can result in severe patient morbidity and mortality. LVAD-specific complications include device malfunction/failure, pump thrombosis, and suction event, while LVAD-associated complications include bleeding, cerebrovascular event, infection, right ventricular failure, dysrhythmia, and aortic regurgitation. Assessment of LVAD function, patient perfusion, and mean arterial pressure is needed upon presentation. Electrocardiogram and bedside ultrasound are key evaluations in the ED. LVAD evaluation and management require a team-based approach, and consultation with the LVAD specialist is recommended. CONCLUSION Emergency clinician knowledge of LVAD function, components, and complications is integral in optimizing care of these patients.
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O'Horo JC, Abu Saleh OM, Stulak JM, Wilhelm MP, Baddour LM, Rizwan Sohail M. Left Ventricular Assist Device Infections: A Systematic Review. ASAIO J 2019; 64:287-294. [PMID: 29095732 PMCID: PMC5920737 DOI: 10.1097/mat.0000000000000684] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Left ventricular assist devices (LVADs) are becoming a more frequent life-support intervention. Gaining an understanding of risk factors for infection and management strategies is important for treating these patients. We conducted a systematic review and meta-analysis of studies describing infections in continuous-flow LVADs. We evaluated incidence, risk factors, associated microorganisms, and outcomes by type of device and patient characteristics. Our search identified 90 distinct studies that reported LVAD infections and outcomes. Younger age and higher body mass index were associated with higher rates of LVAD infections. Driveline infections were the most common infection reported and the easiest to treat with fewest long-term consequences. Bloodstream infections were not reported as often, but they were associated with stroke and mortality. Treatment strategies varied and did not show a consistent best approach. LVAD infections are a significant cause of morbidity and mortality in LVAD patients. Most research comes from secondary analyses of other LVAD studies. The lack of infection-oriented research leaves several areas understudied. In particular, bloodstream infections in this population merit further research. Providers need more research studies to make evidence-based decisions about the prevention and treatment of LVAD infections.
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Affiliation(s)
- John C O'Horo
- From the Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Omar M Abu Saleh
- From the Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark P Wilhelm
- From the Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Larry M Baddour
- From the Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - M Rizwan Sohail
- From the Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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17
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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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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: 64] [Impact Index Per Article: 12.8] [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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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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21
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Colonization With Multiresistant Bacteria: Impact on Ventricular Assist Device Patients. Ann Thorac Surg 2018; 105:557-563. [DOI: 10.1016/j.athoracsur.2017.07.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/07/2017] [Accepted: 07/19/2017] [Indexed: 12/22/2022]
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22
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Sohns JM, Bavendiek U, Ross TL, Bengel FM. Targeting Cardiovascular Implant Infection: Multimodality and Molecular Imaging. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.005376. [PMID: 29222120 DOI: 10.1161/circimaging.117.005376] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Owing to their success in clinical practice, the prevalence of cardiovascular implants is continuously increasing. Implant infection is a relevant complication but remains a diagnostic challenge because echocardiography as a first-line test may be limited. Accordingly, a multimodality approach is increasingly used for diagnostic workup and supported by recent guidelines. As reviewed here, computed tomography and nuclear imaging provide incremental diagnostic value and may be combined in a single hybrid imaging session using positron emission tomography/computed tomography or single photon emission computed tomography/computed tomography. Molecular or cellular imaging helps to overcome the limitations of morphological imaging in implants. Larger-scale clinical studies, earlier application in the time course of diagnosis, monitoring of therapy success, technical advances, and novel radiopharmaceuticals will all contribute to sustained growth of advanced infection-targeted imaging in cardiovascular medicine.
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Affiliation(s)
- Jan M Sohns
- From the Department of Nuclear Medicine (J.M.S., T.L.R., F.M.B.) and Department of Cardiology and Angiology (U.B.), Hanover Medical School, Germany
| | - Udo Bavendiek
- From the Department of Nuclear Medicine (J.M.S., T.L.R., F.M.B.) and Department of Cardiology and Angiology (U.B.), Hanover Medical School, Germany
| | - Tobias L Ross
- From the Department of Nuclear Medicine (J.M.S., T.L.R., F.M.B.) and Department of Cardiology and Angiology (U.B.), Hanover Medical School, Germany
| | - Frank M Bengel
- From the Department of Nuclear Medicine (J.M.S., T.L.R., F.M.B.) and Department of Cardiology and Angiology (U.B.), Hanover Medical School, Germany.
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23
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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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Keenan JB, Rajab TK, Armstrong DG, Khalpey Z. Real-Time Autofluorescence Imaging to Diagnose LVAD Driveline Infections. Ann Thorac Surg 2017; 103:e493-e495. [DOI: 10.1016/j.athoracsur.2016.12.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/08/2016] [Accepted: 12/13/2016] [Indexed: 11/26/2022]
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25
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Hidalgo LF, Shah KB, Cooke RH, Tang DG, Kasirajan V, Cooper HA, Aronow WS. Infections in Patients with a Total Artificial Heart Are Common but Rarely Fatal. ASAIO J 2017; 63:736-739. [PMID: 28319520 DOI: 10.1097/mat.0000000000000562] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Patients who received a total artificial heart (TAH) at Virginia Commonwealth University (VCU) between January 1, 2010 and December 31, 2011 were identified from the VCU Mechanical Circulatory Support Clinical Database. Retrospective data extraction from the medical records was performed from the time of TAH implantation until heart transplantation or death. Infections were classified as confirmed or suspected. Twenty-seven men and five women, mean age 49.5 years (range 24-68 years) received a TAH. The mean duration of TAH support was 225 days (range 1-1,334 days). Of the 32 patients, 4 (12.5%) died and 28 (87.5 %) underwent heart transplantation. Causes of death were pneumonia (n = 1), TAH malfunction (n = 1), refractory cardiogenic shock (n = 1), and respiratory failure (n = 1). Seventy documented and 13 suspected infections developed in 25 patients (78%). The most common sources of infection were urinary tract (n = 26), respiratory tract (n = 18), and bloodstream (n = 11). There were five pump infections and two driveline infections. The number of infections per patient ranged from 0 to 10. Sixteen different pathogens were identified; the most common were: Klebsiella pneumoniae (n = 15), coagulase-negative Staphylococci (n = 10), Enterococcus species (n = 9), and Enterobacter species (n = 8). Mortality directly attributable to infection was infrequent.
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Affiliation(s)
- Luis F Hidalgo
- From the *Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York; †Department of Medicine, Division of Cardiology, Virginia Commonwealth University Medical Center, Richmond, Virginia; and ‡Department of Surgery, Division of Cardiothoracic Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
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26
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Gomez CK, Schiffman SR, Hobbs SK. The Role of Computed Tomography in Predicting Left Ventricular Assist Device Infectious Complications. J Clin Imaging Sci 2016; 6:43. [PMID: 27833783 PMCID: PMC5093873 DOI: 10.4103/2156-7514.192835] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/08/2016] [Indexed: 11/23/2022] Open
Abstract
Objective: The purpose of this study is to identify early computed tomography findings around the driveline which would predict mediastinal or left ventricular assist device (LVAD) pocket abscess formation. Materials and Methods: A retrospective analysis was performed on 128 LVAD recipients between January 2007 and December 2011. Infectious complications were subdivided into those affecting the driveline and those resulting in abscess formation either around the LVAD pump or mediastinum. The size and location of infiltrative changes surrounding the driveline were used to predict infection propagation resulting in abscess. Results: Of the 128 patients, 49 (38.3%) patients developed driveline infections and 24 (18.8%) patients developed abscess. 87.5% patients who developed abscess had a preceding driveline infection. The mean time from driveline infection to the development of pump pocket abscess was approximately 7 months. In addition, patients with abscess in the pump pocket or mediastinum had preceding infiltrative changes surrounding the driveline ≥14 mm (P = 0.0001). A preperitoneal location and size of infiltrative changes ≥14 mm were correlated with a higher likelihood of abscess formation (P = 0.0002). Conclusion: Our study demonstrates the predictive value of infection/infiltrative changes around the driveline, which increases the risk for abscess formation in the LVAD pump pocket and/or in the mediastinum.
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Affiliation(s)
- Carrie K Gomez
- Department of Imaging Sciences, University of Rochester, Rochester, New York, USA
| | - Scott R Schiffman
- Department of Imaging Sciences, University of Rochester, Rochester, New York, USA
| | - Susan K Hobbs
- Department of Imaging Sciences, University of Rochester, Rochester, New York, USA
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27
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The emergency management of ventricular assist devices. Am J Emerg Med 2016; 34:1294-301. [DOI: 10.1016/j.ajem.2016.04.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 04/11/2016] [Accepted: 04/20/2016] [Indexed: 11/18/2022] Open
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28
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Sen A, Larson JS, Kashani KB, Libricz SL, Patel BM, Guru PK, Alwardt CM, Pajaro O, Farmer JC. Mechanical circulatory assist devices: a primer for critical care and emergency physicians. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:153. [PMID: 27342573 PMCID: PMC4921031 DOI: 10.1186/s13054-016-1328-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical circulatory assist devices are now commonly used in the treatment of severe heart failure as bridges to cardiac transplant, as destination therapy for patients who are not transplant candidates, and as bridges to recovery and “decision-making”. These devices, which can be used to support the left or right ventricles or both, restore circulation to the tissues, thereby improving organ function. Left ventricular assist devices (LVADs) are the most common support devices. To care for patients with these devices, health care providers in emergency departments (EDs) and intensive care units (ICUs) need to understand the physiology of the devices, the vocabulary of mechanical support, the types of complications patients may have, diagnostic techniques, and decision-making regarding treatment. Patients with LVADs who come to the ED or are admitted to the ICU usually have nonspecific clinical symptoms, most commonly shortness of breath, hypotension, anemia, chest pain, syncope, hemoptysis, gastrointestinal bleeding, jaundice, fever, oliguria and hematuria, altered mental status, headache, seizure, and back pain. Other patients are seen for cardiac arrest, psychiatric issues, sequelae of noncardiac surgery, and trauma. Although most patients have LVADs, some may have biventricular support devices or total artificial hearts. Involving a team of cardiac surgeons, perfusion experts, and heart-failure physicians, as well as ED and ICU physicians and nurses, is critical for managing treatment for these patients and for successful outcomes. This review is designed for critical care providers who may be the first to see these patients in the ED or ICU.
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Affiliation(s)
- Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Joel S Larson
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Stacy L Libricz
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Bhavesh M Patel
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic Jacksonville, Florida, USA
| | - Cory M Alwardt
- Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Octavio Pajaro
- Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - J Christopher Farmer
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
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Current status of the implantable LVAD. Gen Thorac Cardiovasc Surg 2016; 64:501-8. [PMID: 27270581 DOI: 10.1007/s11748-016-0671-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/29/2016] [Indexed: 10/21/2022]
Abstract
With the ongoing shortage of available organs for heart transplantation, mechanical circulatory support devices have been increasingly utilized for managing acute and chronic heart failure that is refractory to medical therapy. In particular, the introduction of the left ventricular assist devices (LVAD) has revolutionized the field. In this review, we will discuss a brief history of the LVAD, available devices, current indications, patient selection, complications, and outcomes. In addition, we will discuss recent outcomes and advancements in the field of noncardiac surgery in the LVAD patient. Finally, we will discuss several topics for surgical consideration during LVAD implantation.
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30
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Leuck AM. Left ventricular assist device driveline infections: recent advances and future goals. J Thorac Dis 2016; 7:2151-7. [PMID: 26793335 DOI: 10.3978/j.issn.2072-1439.2015.11.06] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Left ventricular assist devices (LVADs) have revolutionized the treatment of advanced heart failure, but infection remains a substantial risk. LVAD driveline infections (DLIs) are the most common type of LVAD-associated infection (LVADI). In the past several years we have expanded our understanding of DLI epidemiology, standardized the definition of LVADIs, improved infection rates through changes in implantation techniques, and investigated potential new modalities for DLI diagnosis. However, significant challenges remain for optimizing DLI prevention and treatment. These challenges include standardizing and improving both empiric and targeted antimicrobial therapy, expanding our understanding of effective driveline exit site dressings and topical therapies, and defining the patient population that benefits from device exchange and transplant. Additionally, in an era of expanding antibiotic resistance we need to continue investigating novel, non-antibiotic therapies for prevention and treatment of DLIs.
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Affiliation(s)
- Anne-Marie Leuck
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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31
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Smith EM, Franzwa J. Chronic outpatient management of patients with a left ventricular assist device. J Thorac Dis 2016; 7:2112-24. [PMID: 26793331 DOI: 10.3978/j.issn.2072-1439.2015.10.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The use of mechanical circulatory support (MCS) as treatment for advanced heart failure (HF) has grown exponentially over the past 15 years. The continuous flow left ventricular assist device (CF-LVAD) has become the most used form of MCS in advanced HF, especially since approval of use as destination therapy (DT) and with the lack of organ availability. Long-term survival has improved and diligent outpatient management is thus particularly critical to achieve optimal outcomes. This review will discuss outpatient management strategies for patients with HF and a left ventricular assist device (LVAD).
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Affiliation(s)
- Elisa M Smith
- 1 Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA ; 2 Cardiomyopathy Treatment Program, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jennifer Franzwa
- 1 Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA ; 2 Cardiomyopathy Treatment Program, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Saritas T, Brandenburg V, Federico G, Gröne HJ, Floege J, Moeller MJ, Moza A. Glomerulonephritis triggered by a chronically infected left ventricular assist device. Lancet 2015; 386:2363-4. [PMID: 26681291 DOI: 10.1016/s0140-6736(15)00822-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Turgay Saritas
- Division of Nephrology and Immunology, University Hospital RWTH Aachen, Germany.
| | | | - Giuseppina Federico
- Department of Cellular and Molecular Pathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann-Josef Gröne
- Department of Cellular and Molecular Pathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Floege
- Division of Nephrology and Immunology, University Hospital RWTH Aachen, Germany; Center for Rare Diseases, University Hospital RWTH Aachen, Germany
| | - Marcus-Johannes Moeller
- Division of Nephrology and Immunology, University Hospital RWTH Aachen, Germany; Center for Rare Diseases, University Hospital RWTH Aachen, Germany
| | - Ajay Moza
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
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Outcomes of Heart Transplant After Left Ventricular Assist Device Specific and Related Infection. Ann Thorac Surg 2015; 100:1292-7. [DOI: 10.1016/j.athoracsur.2015.04.047] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 04/06/2015] [Accepted: 04/09/2015] [Indexed: 11/19/2022]
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Abstract
Heart failure is a chronic progressive disease that affects millions of people in the United States. Although medical management of heart failure has helped improve quality of life and survival, end-stage heart failure ultimately requires a heart transplant or long-term left ventricular assist device (LVAD) support. With more patients awaiting transplant, the demand for hearts outweighs the supply of donor hearts. The use of LVADs is increasing in patients with advanced heart failure as a treatment option for those awaiting a heart transplant or as a long-term solution if they are ineligible for a transplant. Although the LVAD is a marvel of modern medicine, infection is a cause of concern because today’s LVADs are powered externally through a percutaneous driveline that can be a major source of infection.
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Affiliation(s)
- Marc Angud
- Marc Angud is Adult-Gerontology Acute Care Nurse Practitioner Student, Thomas Jefferson University College of Nursing, 901 Walnut Street, Suite 823, Philadelphia, PA 19107
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35
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Towards destination therapy with left ventricular assist devices in Japan. Gen Thorac Cardiovasc Surg 2015; 63:537-9. [PMID: 26281777 DOI: 10.1007/s11748-015-0580-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Indexed: 12/13/2022]
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Kornberger A, Walter V, Khalil M, Therapidis P, Assmus B, Moritz A, Beiras-Fernandez A, Stock UA. Suspected involvement of EPTFE membrane in sterile intrathoracic abscess and pericardial empyema in a multi-allergic LVAD recipient: a case report. J Cardiothorac Surg 2015; 10:99. [PMID: 26183430 PMCID: PMC4504348 DOI: 10.1186/s13019-015-0305-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 06/29/2015] [Indexed: 11/10/2022] Open
Abstract
Device-related infections in recipients of left ventricular assist devices (LVAD) have been recognized as a major source of morbidity and mortality. They require a high level of diagnostic effort as part of the overall burden resulting from infectious complications in LVAD recipients. We present a multi-allergic patient who was treated for persistent sterile intrathoracic abscess formation and pericardial empyema following minimally invasive LVAD implantation including use of a sheet of e-polytetrafluoroethylene (ePTFE) membrane to restore pericardial integrity. Sterile abscess formation and pericardial empyema recurred after surgical removal until the ePTFE membrane was removed, suggesting that in disposed patients, ePTFE may be related to sterile abscess formation or sterile empyema.
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Affiliation(s)
- A Kornberger
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
| | - V Walter
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
| | - M Khalil
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
| | - P Therapidis
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
| | - B Assmus
- Department of Cardiology, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
| | - A Moritz
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
| | - A Beiras-Fernandez
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
| | - U A Stock
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany.
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Abstract
The percentage of elderly patients receiving left ventricular assist devices (LVADs) has increased; thus, a rise in the frequency of elderly prevalent diseases would be expected in LVAD-supported patients. Cancer is the second leading cause of death in the United States, and the frequency of cancer and the mortality rate of malignancies increase with age. We describe the clinical characteristics of eight patients who were diagnosed of cancer after LVAD implantation. Skin, esophageal, central nervous system (CNS), hematological and renal malignancies were observed. After careful consideration, these patients underwent surgical resections, radiotherapy, radiofrequency ablation, and chemotherapy with variable results. Patients who developed cancer were older males who received LVAD predominantly as destination therapy. Skin cancer and hematological malignancy were managed with standard oncologic treatment. Renal cell carcinoma was monitored, and a CNS tumor was treated aggressively but as expected had a poor outcome. Esophageal cancer, although localized, represented a serious therapeutic challenge, as patients were unable to undergo a potentially curative surgical procedure because of the anatomic location of malignancy. More information is needed regarding the outcomes and best treatment strategies for this newly identified population.
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Shah KB, Smallfield MC, Tang DG, Malhotra R, Cooke RH, Kasirajan V. Mechanical circulatory support devices in the ICU. Chest 2015; 146:848-857. [PMID: 25180728 DOI: 10.1378/chest.13-2645] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The medical community has used implantable mechanical circulatory support devices at increasing rates for patients dying from heart failure and cardiogenic shock. Newer-generation devices offer a more durable and compact option when compared with bulky early-generation devices. This article is a succinct introduction and overview of the hemodynamic principles and complications after device implantation for ICU clinicians. We review the concepts of device physiology, clinical pearls for perioperative management, and common medical complications after device implantation.
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Affiliation(s)
- Keyur B Shah
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA.
| | | | - Daniel G Tang
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Rajiv Malhotra
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard H Cooke
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Vigneshwar Kasirajan
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA
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Modified HeartMate II Driveline Externalization Technique Significantly Decreases Incidence of Infection and Improves Long-Term Survival. ASAIO J 2014; 60:613-6. [DOI: 10.1097/mat.0000000000000121] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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40
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Walton ZJ, Holmes RE, Rac G, Nelson EW, Leddy LR. Total Hip Arthroplasty in a Patient with a Left Ventricular Assist Device: A Case Report. JBJS Case Connect 2014; 4:e61. [PMID: 29252500 DOI: 10.2106/jbjs.cc.m.00286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Zeke J Walton
- Departments of Orthopaedic Surgery (Z.J.W., R.E.H., and L.R.L.), and Anesthesia (E.W.N.), Medical University of South Carolina School of Medicine (G.R.), 96 Jonathan Lucas Street, Suite 708, Charleston, SC 27425
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41
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Thanavaro KL, Nixon J(I. Endocarditis 2014: An update. Heart Lung 2014; 43:334-7. [DOI: 10.1016/j.hrtlng.2014.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/16/2014] [Accepted: 03/23/2014] [Indexed: 10/25/2022]
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