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Wasilewski G, Wiśniowska-Śmiałek S, Górkiewicz-Kot I, Milaniak I, Kaleta M, Hymczak H, Wasilewska A, Wierzbicki K. Driveline Infection in Patients With Left Ventricular Assist Devices Implanted as Destination Therapy. Transplant Proc 2024; 56:860-863. [PMID: 38734518 DOI: 10.1016/j.transproceed.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 12/29/2023] [Accepted: 03/29/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Donor organ shortages cause increasing demand for mechanical circulatory support in patients with end-stage heart failure not only as a bridge to heart transplantation but mainly as a destination therapy. Improved results and increased applicability and durability of left ventricular assist devices (LVADs) have established this treatment option as an alternative to heart transplantation in selected patients. One of the most common complications after LVAD implantation is driveline infections (DLIs). METHODS This study aimed to expand the understanding of DLI epidemiology and potential changes in implantation techniques regarding optimizing DLI prevention and treatment among all patients undergoing LVAD (Medtronic's Heartware HVAD and HeartMate 3 Abbott LVAD system) implantation with at least 12 months of follow-up time between 2015 and 2022. RESULTS There were 120 individuals with LVAD implantation, of whom 90 had 12 months of follow-up (85 men [94%], 5 women [6%]) with a median age of 58 years (50.25-63.75). The median body mass index was 27.12 kg/m2 (25.27-29.68). Of the 90 patients, 43 had ischemic heart failure (48%), 43 had dilated cardiomyopathy (48%), and the remaining 3 had other etiologies (3%), such as postinflammatory, and the remaining 1 had congenital heart defect (1%). Preoperative echocardiography revealed a mean left ventricle ejection fraction of 13.8% and a median left ventricle dimension of 7.55 cm (6.92-8.2). Imaging confirmed pulmonary hypertension in 61 patients (68%). Thirty-four of the 90 patients had diabetes (38%), and 16 were active smokers (18%). Median follow-up was 30 months (17.25-42), with the longest period being 82 months. More than half of the patients (n = 52; 57%) experienced a DLI. The median time to the first episode of DLI was 13 months (6-25). The most common pathogen revealed in wound swab culture was methicillin-sensitive Staphylococcus aureus (n = 23; 44%), Pseudomonas aeruginosa (n = 9; 17%), Proteus mirabilis (n = 4; 7%), and others. We observed that deeper driveline implantation below the left rectus muscle and just above the posterior rectus sheath resulted in fewer DLIs and longer free-from-DLI follow-up time. There was no statistically significant difference in DLI frequency between patients with or without diabetes mellitus. CONCLUSIONS Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of destination therapy. DLI is the most common complication after LVAD implantation. Optimal surgical techniques and early implementation of targeted antibiotics are crucial. Significant challenges remain in optimizing DLI prevention and treatment.
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Affiliation(s)
- Grzegorz Wasilewski
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul II Hospital, Cracow, Poland.
| | - Sylwia Wiśniowska-Śmiałek
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul II Hospital, Cracow, Poland
| | - Izabela Górkiewicz-Kot
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul II Hospital, Cracow, Poland
| | - Irena Milaniak
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul II Hospital, Cracow, Poland
| | - Michał Kaleta
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul II Hospital, Cracow, Poland
| | - Hubert Hymczak
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul II Hospital, Cracow, Poland
| | - Agata Wasilewska
- Department of Pediatric and Gastroenterology, Jagiellonian University, Medical College, Cracow, Poland
| | - Karol Wierzbicki
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul II Hospital, Cracow, Poland
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Pallotto C, Tordi S, Pantanella R, Rosignoli D, Francisci D. Dalbavancin as chronic antibiotic suppression therapy for left ventricular assist device driveline infection due to methicillin-resistant Staphylococcus aureus: a case report. J Chemother 2022:1-5. [PMID: 36281721 DOI: 10.1080/1120009x.2022.2136426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Left Ventricular Assist Devices (LVADs) represent an important therapeutic option in the management of advanced heart failure. We report a case of 74 years-old male with a Jarvik 2000® (Jarvik Heart, New York, USA) LVAD who presented with an infection of the LVAD driveline due to methicillin-resistant Staphylococcus aureus (MRSA) that was treated with dalbavancin as chronic antimicrobial suppression therapy without adverse events and maintaining a good quality of life for more than 37 weeks. Dalbavancin could represent a valid option for the treatment of LVAD infections because of its efficacy, pharmacokinetic/pharmacodynamic proprieties, safety and tolerability.
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Affiliation(s)
- Carlo Pallotto
- Infectious Diseases Clinic, Santa Maria della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Sara Tordi
- Infectious Diseases Clinic, Santa Maria della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Romina Pantanella
- Department of Cardiac Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Daniele Rosignoli
- Infectious Diseases Clinic, Santa Maria della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Daniela Francisci
- Infectious Diseases Clinic, Santa Maria della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Shah SAR, Hayat A, Kumar S. Letter to the Editor: Impact of antimicrobial selection for prophylaxis of left ventricular assist device surgical infections. J Card Surg 2022; 37:1801. [PMID: 35338715 DOI: 10.1111/jocs.16440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Syed A R Shah
- Dow University of Health Sciences, Karachi, Pakistan
| | - Ahmad Hayat
- Punjab Medical College, Faisalabad, Pakistan
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
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Rustum S, Neuser J, Schmitto JD, Aper T, Hanke JS, Haverich A, Wilhelmi M. Vascular procedures in patients with left ventricular assist devices: single-center experience. Indian J Thorac Cardiovasc Surg 2021; 37:514-520. [PMID: 34511757 PMCID: PMC8387529 DOI: 10.1007/s12055-021-01192-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
Objective A growing number of patients suffering from heart failure is living with a left ventricular assist device (LVAD) and is in the need for non-cardiac surgery. Vascular procedures due to ischemia, bleeding, or other device-related complications may be required and pose a challenge to the caregivers in terms of monitoring and management of these patients. Therefore, we reviewed our experience with LVAD patients undergoing vascular surgery. Methods From January 2010 until March 2017, a total of 54 vascular procedures were performed on 41 LVAD patients at our institution. Patient records were reviewed retrospectively in terms of incidence of LVAD-related complications, including thrombosis, stroke, bleeding, wound healing, and survival associated with vascular surgery. The type of surgery was recorded, as well as various clinical demographic variables. Results Vascular procedures were performed in 35 men (85.4%) and 6 women (14.6%) with LVADs. There were no perioperative strokes, device thromboses, or device malfunctions. Thirty-day mortality overall was 26.8% (eleven patients), with most patients dying within 30 days after LVAD implantation due to multi-organ failure. In 25 procedures (46.3%), a blood transfusion was necessary. Conclusion Patients on LVAD support are a complex cohort with a high risk for perioperative complications. In a setting where device function and anticoagulation are monitored closely, vascular surgery in these patients is feasible with an acceptable perioperative risk.
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Affiliation(s)
- Saad Rustum
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Julia Neuser
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Jan Dieter Schmitto
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Thomas Aper
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Jasmin Sarah Hanke
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Axel Haverich
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Mathias Wilhelmi
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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Hehr JD, Hodson TS, West JM, Schulz SA, Poteet SJ, Chandawarkar RY, Valerio IL. Instillation negative pressure wound therapy: An effective approach for hardware salvage. Int Wound J 2019; 17:387-393. [PMID: 31858713 DOI: 10.1111/iwj.13283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 12/21/2022] Open
Abstract
Wound infection involving hardware can be notoriously difficult to treat, often requiring the removal of the infected implant. The goal of this study was to determine the utility of instillation negative pressure wound therapy to help eradicate infection and allow for definitive wound closure in patients without removing the infected hardware. A retrospective review was performed on the outcomes of 28 patients who presented with open wounds with exposed or infected hardware and who were treated with a combination of surgical debridement and negative pressure wound therapy with instillation (NPWTi). Eleven patients were treated for infected spinal hardware, 12 for extremity, and 5 for sternal hardware. Twenty-five of 28 (89%) patients had successful retention or replacement of hardware, with clearance of infection and healed wounds. Original hardware was maintained in 17 of 28 (61%) patients. In 11 patients, original hardware was removed, with subsequent replacement in eight of those patients after a clean wound was achieved. Average time to definitive closure was 12.6 days. Average follow-up was 135 days. This series supports NPWTi as an effective adjunct therapy to help expeditiously eradicate hardware infection, allowing for hardware retention.
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Affiliation(s)
- Jason D Hehr
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Trevor S Hodson
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julie M West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Steven A Schulz
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Stephen J Poteet
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rajiv Y Chandawarkar
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ian L Valerio
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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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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Cabrera AG, Ahmed M, Checchia PA. Commentary: Light, and maybe less bacteria, at the end of the tunnel? J Thorac Cardiovasc Surg 2019; 159:503-504. [PMID: 31101347 DOI: 10.1016/j.jtcvs.2019.03.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Antonio G Cabrera
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex
| | - Mubbasheer Ahmed
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex.
| | - Paul A Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex
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Hodson T, West JM, Poteet SJ, Lee PH, Valerio IL. Instillation Negative Pressure Wound Therapy: A Role for Infected LVAD Salvage. Adv Wound Care (New Rochelle) 2019; 8:118-124. [PMID: 31737410 DOI: 10.1089/wound.2018.0832] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/21/2018] [Indexed: 01/02/2023] Open
Abstract
Objective: To determine the utility of instillation negative pressure wound therapy (NPWT) in achieving eradication of infection and definitive wound closure in patients with infected left ventricular assist device (LVAD). Approach: A retrospective review was performed in a series of patients with infected and exposed LVADs who were treated with instillation NPWT in conjunction with surgical debridement. Results: Three consecutive patients were included who developed periprosthetic infection subsequent to LVAD implantation. In all cases, the utilization of a vacuum-assisted closure with instillation (VACi) along with surgical debridement and IV antibiotics eradicated infection resulting in successful retention of hardware. Cases 1 and 2 received definitive wound closure within 3 and 12 days of starting treatment, respectively. Case 3 initially deferred surgery in favor of local wound care. Eventually the patient elected for surgical treatment and underwent closure 164 days after initial presentation. All three patients healed completely without residual evidence of infection. Flap reconstruction with a pedicled rectus flap was used to achieve definitive closure in all patients. One patient subsequently required pump replacement secondary to thrombosis and mechanical pump failure. Innovation: LVAD infections are met with high morbidity and mortality rates, and timely salvage is critical. In this initial series, VACi has proven a viable therapy option to help control and eradicate infection without LVAD removal. Conclusion: This series illustrates the value of newer techniques such as VACi in combination with surgical debridement and antibiotic therapy in effectively salvaging LVADs that were infected.
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Affiliation(s)
- Trevor Hodson
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julie M. West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Stephen J. Poteet
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter H. Lee
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ian L. Valerio
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Hernandez GA, Blumer V, Arcay L, Monge J, Viles-Gonzalez JF, Lindenfeld J, Goldberger JJ, Chaparro S. Cardiac Resynchronization Therapy in Inotrope-Dependent Heart Failure Patients. JACC-HEART FAILURE 2018; 6:734-742. [DOI: 10.1016/j.jchf.2018.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/20/2018] [Accepted: 02/27/2018] [Indexed: 12/30/2022]
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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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