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Qu Y, McGiffin D, Sanchez LD, Gengenbach T, Easton C, Thissen H, Peleg AY. Anti-infective characteristics of a new Carbothane ventricular assist device driveline. Biofilm 2023; 5:100124. [PMID: 37153749 PMCID: PMC10154736 DOI: 10.1016/j.bioflm.2023.100124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/10/2023] [Accepted: 04/15/2023] [Indexed: 05/10/2023] Open
Abstract
Objectives Driveline infections are a major complication of ventricular assist device (VAD) therapy. A newly introduced Carbothane driveline has preliminarily demonstrated anti-infective potential against driveline infections. This study aimed to comprehensively assess the anti-biofilm capability of the Carbothane driveline and explore its physicochemical characteristics. Methods We assessed the Carbothane driveline against biofilm formation of leading microorganisms causing VAD driveline infections, including Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa and Candida albicans, using novel in vitro biofilm assays mimicking different infection micro-environments. The importance of physicochemical properties of the Carbothane driveline in microorganism-device interactions were analyzed, particularly focusing on the surface chemistry. The role of micro-gaps in driveline tunnels on biofilm migration was also examined. Results All organisms were able to attach to the smooth and velour sections of the Carbothane driveline. Early microbial adherence, at least for S. aureus and S. epidermidis, did not proceed to the formation of mature biofilms in a drip-flow biofilm reactor mimicking the driveline exit site environment. The presence of a driveline tunnel however, promoted staphylococcal biofilm formation on the Carbothane driveline. Physicochemical analysis of the Carbothane driveline revealed surface characteristics that may have contributed to its anti-biofilm activity, such as the aliphatic nature of its surface. The presence of micro-gaps in the tunnel facilitated biofilm migration of the studied bacterial species. Conclusion This study provides experimental evidence to support the anti-biofilm activity of the Carbothane driveline and uncovered specific physicochemical features that may explain its ability to inhibit biofilm formation.
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Affiliation(s)
- Yue Qu
- Infection Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred and Monash University, Melbourne, Victoria, 3004, Australia
| | - Lina Duque Sanchez
- Commonwealth Scientific and Industrial Research Organization (CSIRO) Manufacturing, Clayton, Victoria, 3168, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, 3052, Australia
| | - Thomas Gengenbach
- Commonwealth Scientific and Industrial Research Organization (CSIRO) Manufacturing, Clayton, Victoria, 3168, Australia
| | - Chris Easton
- Commonwealth Scientific and Industrial Research Organization (CSIRO) Manufacturing, Clayton, Victoria, 3168, Australia
| | - Helmut Thissen
- Commonwealth Scientific and Industrial Research Organization (CSIRO) Manufacturing, Clayton, Victoria, 3168, Australia
| | - Anton Y. Peleg
- Infection Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
- Corresponding author. Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.
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2
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Kourouklis AP, Kaemmel J, Wu X, Baños M, Chanfon A, de Brot S, Ferrari A, Cesarovic N, Falk V, Mazza E. Transdermal wires for improved integration in vivo. BIOMATERIALS ADVANCES 2023; 153:213568. [PMID: 37591177 DOI: 10.1016/j.bioadv.2023.213568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/13/2023] [Accepted: 07/23/2023] [Indexed: 08/19/2023]
Abstract
Alternative engineering approaches have led the design of implants with controlled physical features to minimize adverse effects in biological tissues. Similar efforts have focused on optimizing the design features of percutaneous VAD drivelines with the aim to prevent infection, omitting however a thorough look on the implant-skin interactions that govern local tissue reactions. Here, we utilized an integrated approach for the biophysical modification of transdermal implants and their evaluation by chronic sheep implantation in comparison to the standard of care VAD drivelines. We developed a novel method for the transfer of breath topographical features on thin wires with modular size. We examined the impact of implant's diameter, surface topography, and chemistry on macroscopic, histological, and physical markers of inflammation, fibrosis, and mechanical adhesion. All implants demonstrated infection-free performance. The fibrotic response was enhanced by the increasing diameter of implants but not influenced by their surface properties. The implants of small diameter promoted mild inflammatory responses with improved mechanical adhesion and restricted epidermal downgrowth, in both silicone and polyurethane coated transdermal wires. On the contrary, the VAD drivelines with larger diameter triggered severe inflammatory reactions with frequent epidermal downgrowth. We validated these effects by quantifying the infiltration of macrophages and the level of vascularization in the fibrotic zone, highlighting the critical role of size reduction for the benign integration of transdermal implants with skin. This insight on how the biophysical properties of implants impact local tissue reactions could enable new solutions on the transdermal transmission of power, signal, and mass in a broad range of medical devices.
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Affiliation(s)
- Andreas P Kourouklis
- Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zurich, 8092 Zurich, Switzerland
| | - Julius Kaemmel
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany
| | - Xi Wu
- Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zurich, 8092 Zurich, Switzerland
| | - Miguel Baños
- Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zurich, 8092 Zurich, Switzerland
| | - Astrid Chanfon
- COMPATH, Institute of Animal Pathology, University of Bern, 3012 Bern, Switzerland
| | - Simone de Brot
- COMPATH, Institute of Animal Pathology, University of Bern, 3012 Bern, Switzerland
| | - Aldo Ferrari
- EMPA, Swiss Federal Laboratories for Material Science and Technology, 8600 Dübendorf, Switzerland
| | - Nikola Cesarovic
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; Department of Health Sciences and Technology, ETH Zürich, 8093 Zürich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; Department of Health Sciences and Technology, ETH Zürich, 8093 Zürich, Switzerland
| | - Edoardo Mazza
- Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zurich, 8092 Zurich, Switzerland; EMPA, Swiss Federal Laboratories for Material Science and Technology, 8600 Dübendorf, Switzerland.
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3
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Tsuji M, Kakuda N, Bujo C, Saito A, Ishida J, Amiya E, Hatano M, Shimada A, Imai H, Kimura M, Ando M, Kinoshita O, Yamauchi H, Komuro I, Ono M. Prophylactic negative pressure wound therapy is not effective for preventing driveline infection following left ventricular assist device implantation. Artif Organs 2023; 47:566-573. [PMID: 36300650 DOI: 10.1111/aor.14440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/10/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Driveline infection (DLI) following left ventricular assist device (LVAD) implantation remains an unresolved problem. Negative pressure wound therapy (NPWT) promotes wound healing by applying negative pressure on the surface of the wound. Recently, the prophylactic application of NPWT to closed surgical incisions has decreased surgical site infections in various postsurgical settings. Therefore, we evaluated the efficacy and safety of prophylactic NPWT for preventing DLI in patients with LVAD implantation. METHODS Prophylactic NPWT was provided to 50 patients who received continuous-flow LVADs as bridge-to-transplant therapy at our institution between May 2018 and October 2020 (NPWT group). The negative pressure dressing was applied immediately after surgery and retained on the driveline exit site for 7 days with a continuous application of -125 mm Hg negative pressure. The primary outcome was DLI within 1 year of LVAD implantation. We compared the rate of DLI incidence in the NPWT group with that in the historical control cohort (50 patients) treated with the standard dressing (SD) who received LVAD implantation between July 2015 and April 2018 (SD group). RESULTS No severe complications were associated with the NPWT. During the follow-up period, DLI was diagnosed in 16 participants (32%) in the NPWT group and 21 participants (42%) in the SD group. The rates of DLI incidence and freedom from DLI did not differ between groups (p = 0.30 and p = 0.63). CONCLUSIONS Prophylactic NPWT at the driveline exit site was safe following LVAD implantation. However, it did not significantly reduce the risk of DLI.
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Affiliation(s)
- Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Advanced Medical Center for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Asako Shimada
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroko Imai
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Kinoshita
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruo Yamauchi
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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4
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Seretny J, Pidborochynski T, Buchholz H, Freed DH, MacArthur R, Dubyk N, Cunliffe L, Zelaya O, Conway J. Decreasing driveline infections in patients supported on ventricular assist devices: a care pathway approach. BMJ Open Qual 2022; 11:bmjoq-2022-001815. [PMID: 35649636 PMCID: PMC9161071 DOI: 10.1136/bmjoq-2022-001815] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
Background Driveline infections (DLIs) are a common adverse event in patients on ventricular assist devices (VADs) with incidence ranging from 14% to 59%. DLIs have an impact on patients and the healthcare system with efforts to prevent DLIs being essential. Prior to our intervention, our program had no standard driveline management presurgery and postsurgery. The purpose of this Quality Improvement (QI) initiative was to reduce DLIs and related admissions among patients with VAD within the first year post implant. Methods In anticipation of the QI project, we undertook a review of the programs’ current driveline management procedures and completed a survey with patients with VAD to identify current barriers to proper driveline management. Retrospective data were collected for a pre-QI intervention baseline comparison group, which included adult patients implanted with a durable VAD between 1 January 2017 and 31 July 2018. A three-pronged care pathway (CP) was initiated among patients implanted during August 2018 to July 2019. The CP included standardised intraoperative, postoperative and predischarge teaching initiatives and tracking. Using statistical process control methods, DLIs and readmissions in the first year post implant were compared between patients in the CP group and non-CP patients. P-charts were used to detect special cause variation. Results A higher proportion of CP group patients developed a DLI in the first year after implant (52% vs 32%). None developed a DLI during the index admission, which differed from the non-CP group and met criteria for special cause variation. There was a downward trend in cumulative DLI-related readmissions among CP group patients (55% vs 67%). There was no association between CP compliance and development of DLIs within 1 year post implant. Conclusion The CP did not lead to a reduction in the incidence of DLIs but there was a decrease in the proportion of patients with DLIs during their index admission and those readmitted for DLIs within 1 year post implant. This suggests that the CP played a role in decreasing the impact of DLIs in this patient population. However, given the short time period of follow-up longer follow-up will be required to look for sustained effects.
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Affiliation(s)
- Julia Seretny
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Tara Pidborochynski
- Pediatric Cardiology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Holger Buchholz
- Department of Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Darren H Freed
- Department of Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Roderick MacArthur
- Department of Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Nicole Dubyk
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Laura Cunliffe
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Osiris Zelaya
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Pediatric Cardiology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Kranzl M, Stoiber M, Schaefer AK, Riebandt J, Wiedemann D, Marko C, Laufer G, Zimpfer D, Schima H, Schlöglhofer T. Driveline Features as Risk Factor for Infection in Left Ventricular Assist Devices: Meta-Analysis and Experimental Tests. Front Cardiovasc Med 2021; 8:784208. [PMID: 34977190 PMCID: PMC8716483 DOI: 10.3389/fcvm.2021.784208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Risk factors for driveline infection (DLI) in patients with left ventricular assist devices are multifactorial. The aim of this study was to analyze the correlation between mechanical driveline features and DLI occurrence. Methods: A meta-analysis was conducted that included studies reporting DLI rates at 6 months after implantation of any of three contemporary devices (HVAD with Pellethane or Carbothane driveline, HeartMate II, and HeartMate 3). Further, outer driveline diameter measurements and ex-vivo experimental three-point bending and torsion tests were performed to compare the stiffness of the four different driveline types. Results: 21 studies with 5,393 patients were included in the meta-analysis. The mean weighted DLI rates ranged from 7.2% (HeartMate II) to 11.9% (HeartMate 3). The HeartMate II driveline had a significantly lower maximal bending force (Loadmax) (4.52 ± 0.19 N) compared to the Carbothane HVAD (8.50 ± 0.08 N), the HeartMate 3 (11.08 ± 0.3 N), and the Pellethane HVAD driveline (15.55 ± 0.14 N) (p < 0.001). The maximal torque (Torquemax) of the HeartMate II [41.44 (12.61) mNm] and the Carbothane HVAD driveline [46.06 (3.78) mNm] were significantly lower than Torquemax of the Pellethane HVAD [46.06 (3.78) mNm] and the HeartMate 3 [95.63 (26.60) mNm] driveline (p < 0.001). The driveline of the HeartMate 3 had the largest outer diameter [6.60 (0.58) mm]. A relationship between the mean weighted DLI rate and mechanical driveline features (Torquemax) was found, as the the HeartMate II driveline had the lowest Torquemax and lowest DLI rate, whereas the HeartMate 3 driveline had the highest Torquemax and highest DLI rate. Conclusions: Device-specific mechanical driveline features are an additional modifiable risk factor for DLI and may influence clinical outcomes of LVAD patients.
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Affiliation(s)
- Melanie Kranzl
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Stoiber
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | | | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Christiane Marko
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
| | - Heinrich Schima
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
- *Correspondence: Thomas Schlöglhofer ; orcid.org/0000-0003-4354-4860
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Kaemmel J, Ferrari A, Robotti F, Bottan S, Eichenseher F, Schmidt T, Gonzalez Moreno M, Trampuz A, Eulert-Grehn JJ, Knosalla C, Potapov E, Falk V, Starck C. On the function of biosynthesized cellulose as barrier against bacterial colonization of VAD drivelines. Sci Rep 2021; 11:18776. [PMID: 34548588 PMCID: PMC8455583 DOI: 10.1038/s41598-021-98220-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/01/2021] [Indexed: 12/28/2022] Open
Abstract
Bacterial colonization of drivelines represents a major adverse event in the implantation of left ventricular assist devices (L-VADs) for the treatment of congestive heart failure. From the external driveline interface and through the skin breach, pathogens can ascend to the pump pocket, endangering the device function and the patient’s life. Surface Micro-Engineered Biosynthesized cellulose (BC) is an implantable biomaterial, which minimizes fibrotic tissue deposition and promotes healthy tissue regeneration. The topographic arrangement of cellulose fibers and the typical material porosity support its potential protective function against bacterial permeation; however, this application has not been tested in clinically relevant animal models. Here, a goat model was adopted to evaluate the barrier function of BC membranes. The external silicone mantle of commercial L-VAD drivelines was implanted percutaneously with an intervening layer of BC to separate them from the surrounding soft tissue. End-point evaluation at 6 and 12 weeks of two separate animal groups revealed the local bacterial colonization at the different interfaces in comparison with unprotected driveline mantle controls. The results demonstrate that the BC membranes established an effective barrier against the bacterial colonization of the outer driveline interface. The containment of pathogen infiltration, in combination with the known anti-fibrotic effect of BC, may promote a more efficient immune clearance upon driveline implantation and support the efficacy of local antibiotic treatments, therefore mitigating the risk connected to their percutaneous deployment.
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Affiliation(s)
- Julius Kaemmel
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Aldo Ferrari
- Hylomorph AG, Technoparkstrasse 1, 8005, Zurich, Switzerland
| | - Francesco Robotti
- Hylomorph AG, Technoparkstrasse 1, 8005, Zurich, Switzerland.,Wyss Zurich, Zurich, Switzerland
| | - Simone Bottan
- Hylomorph AG, Technoparkstrasse 1, 8005, Zurich, Switzerland
| | - Fritz Eichenseher
- Food Microbiology Laboratory, ETH Zurich, Schmelzbergstrasse 7, 8092, Zurich, Switzerland
| | - Tanja Schmidt
- Forschungseinrichtungen für Experimentelle Medizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mercedes Gonzalez Moreno
- Charité-Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117, Berlin, Germany
| | - Jaime-Jürgen Eulert-Grehn
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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7
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Krzelj K, Petricevic M, Gasparovic H, Biocina B, McGiffin D. Ventricular Assist Device Driveline Infections: A Systematic Review. Thorac Cardiovasc Surg 2021; 70:493-504. [PMID: 34521143 DOI: 10.1055/s-0041-1731823] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Infection is the most common complication in patients undergoing ventricular assist device (VAD) implantation. Driveline exit site (DLES) infection is the most frequent VAD infection and is a significant cause of adverse events in VAD patients, contributing to morbidity, even mortality, and repetitive hospital readmissions. There are many risk factors for driveline infection (DLI) including younger age, smaller constitution of patients, obesity, exposed velour at the DLES, longer duration of device support, lower cardiac index, higher heart failure score, DLES trauma, and comorbidities such as diabetes mellitus, chronic kidney disease, and depression. The incidence of DLI depends also on the device type. Numerous measures to prevent DLI currently exist. Some of them are proven, whereas the others remain controversial. Current recommendations on DLES care and DLI management are predominantly based on expert consensus and clinical experience of the certain centers. However, careful and uniform DLES care including obligatory driveline immobilization, previously prepared sterile dressing change kits, and continuous patient education are probably crucial for prevention of DLI. Diagnosis and treatment of DLI are often challenging because of certain immunological alterations in VAD patients and microbial biofilm formation on the driveline surface areas. Although there are many conservative and surgical methods described in the DLI treatment, the only possible permanent solution for DLI resolution in VAD patients is heart transplantation. This systematic review brings a comprehensive synthesis of recent data on the prevention, diagnostic workup, and conservative and surgical management of DLI in VAD patients.
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Affiliation(s)
- Kristina Krzelj
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mate Petricevic
- Division of Health Studies, Department of Cardiac Surgery, University of Split, University Hospital Center Zagreb, Zagreb, Croatia
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - David McGiffin
- Department of Cardiothoracic Surgery and Transplantation, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Clayton, Victoria, Australia
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8
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Systems of conductive skin for power transfer in clinical applications. EUROPEAN BIOPHYSICS JOURNAL: EBJ 2021; 51:171-184. [PMID: 34477935 PMCID: PMC8964546 DOI: 10.1007/s00249-021-01568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/29/2021] [Accepted: 08/12/2021] [Indexed: 11/03/2022]
Abstract
The primary aim of this article is to review the clinical challenges related to the supply of power in implanted left ventricular assist devices (LVADs) by means of transcutaneous drivelines. In effect of that, we present the preventive measures and post-operative protocols that are regularly employed to address the leading problem of driveline infections. Due to the lack of reliable wireless solutions for power transfer in LVADs, the development of new driveline configurations remains at the forefront of different strategies that aim to power LVADs in a less destructive manner. To this end, skin damage and breach formation around transcutaneous LVAD drivelines represent key challenges before improving the current standard of care. For this reason, we assess recent strategies on the surface functionalization of LVAD drivelines, which aim to limit the incidence of driveline infection by directing the responses of the skin tissue. Moreover, we propose a class of power transfer systems that could leverage the ability of skin tissue to effectively heal short diameter wounds. In this direction, we employed a novel method to generate thin conductive wires of controllable surface topography with the potential to minimize skin disruption and eliminate the problem of driveline infections. Our initial results suggest the viability of the small diameter wires for the investigation of new power transfer systems for LVADs. Overall, this review uniquely compiles a diverse number of topics with the aim to instigate new research ventures on the design of power transfer systems for IMDs, and specifically LVADs.
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9
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Ventricular Assist Device-Specific Infections. J Clin Med 2021; 10:jcm10030453. [PMID: 33503891 PMCID: PMC7866069 DOI: 10.3390/jcm10030453] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 12/30/2022] Open
Abstract
Ventricular assist device (VAD)-specific infections, in particular, driveline infections, are a concerning complication of VAD implantation that often results in significant morbidity and even mortality. The presence of a percutaneous driveline at the skin exit-site and in the subcutaneous tunnel allows biofilm formation and migration by many bacterial and fungal pathogens. Biofilm formation is an important microbial strategy, providing a shield against antimicrobial treatment and human immune responses; biofilm migration facilitates the extension of infection to deeper tissues such as the pump pocket and the bloodstream. Despite the introduction of multiple preventative strategies, driveline infections still occur with a high prevalence of ~10-20% per year and their treatment outcomes are frequently unsatisfactory. Clinical diagnosis, prevention and management of driveline infections are being targeted to specific microbial pathogens grown as biofilms at the driveline exit-site or in the driveline tunnel. The purpose of this review is to improve the understanding of VAD-specific infections, from basic "bench" knowledge to clinical "bedside" experience, with a specific focus on the role of biofilms in driveline infections.
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10
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Schlöglhofer T, Michalovics P, Riebandt J, Angleitner P, Stoiber M, Laufer G, Schima H, Wiedemann D, Zimpfer D, Moscato F. Left ventricular assist device driveline infections in three contemporary devices. Artif Organs 2020; 45:464-472. [PMID: 33052592 PMCID: PMC8247301 DOI: 10.1111/aor.13843] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 12/20/2022]
Abstract
Driveline infections (DLI) are common adverse events in left ventricular assist devices (LVADs), leading to severe complications and readmissions. The study aims to characterize risk factors for DLI readmission 2 years postimplant. This single‐center study included 183 LVAD patients (43 HeartMate II [HMII], 29 HeartMate 3 [HM3], 111 HVAD) following hospital discharge between 2013 and 2017. Demographics, clinical parameters, and outcomes were retrospectively analyzed and 12.6% of patients were readmitted for DLI, 14.8% experienced DLI but were treated in the outpatient setting, and 72.7% had no DLI. Mean C‐reactive protein (CRP), leukocytes and fibrinogen were higher in patients with DLI readmission (P < .02) than in outpatient DLI and patients without DLI, as early as 60 days before readmission. Freedom from DLI readmission was comparable for HMII and HVAD (98% vs. 87%; HR, 4.52; 95% CI, 0.58‐35.02; P = .15) but significantly lower for HM3 (72%; HR, 10.82; 95% CI, 1.26‐92.68; P = .03). DLI (HR, 1.001; 95% CI, 0.999‐1.002; P = .16) or device type had no effect on mortality. DLI readmission remains a serious problem following LVAD implantation, where CRP, leukocytes, and fibrinogen might serve as risk factors already 60 days before. HM3 patients had a higher risk for DLI readmissions compared to HVAD or HMII, possibly because of device‐specific driveline differences.
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Affiliation(s)
- Thomas Schlöglhofer
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
| | - Peter Michalovics
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Angleitner
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Stoiber
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
| | - Heinrich Schima
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
| | - Dominik Wiedemann
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria
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11
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Zinoviev R, Lippincott CK, Keller SC, Gilotra NA. In Full Flow: Left Ventricular Assist Device Infections in the Modern Era. Open Forum Infect Dis 2020; 7:ofaa124. [PMID: 32405511 PMCID: PMC7209633 DOI: 10.1093/ofid/ofaa124] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
With the rising prevalence of heart disease in the United States, there is increasing reliance on durable mechanical circulatory support (MCS) to treat patients with end-stage heart failure. Left ventricular assist devices (LVADs), the most common form of durable MCS, are implanted mechanical pumps that connect to an external power source through a transcutaneous driveline. First-generation LVADs were bulky, pulsatile pumps that were frequently complicated by infection. Second-generation LVADs have an improved design, though infection remains a common and serious complication due to the inherent nature of implanted MCS. Infections can affect any component of the LVAD, with driveline infections being the most common. LVAD infections carry significant morbidity and mortality for LVAD patients. Therefore, it is paramount for the multidisciplinary team of clinicians caring for these patients to be familiar with this complication. We review the epidemiology, prevention, diagnosis, treatment, and outcomes of LVAD infections.
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Affiliation(s)
- Radoslav Zinoviev
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher K Lippincott
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sara C Keller
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Department of Medicine - Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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12
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Significant impact of left ventricular assist device models on the value of flow-mediated dilation: effects of LVAD on endothelial function. Heart Vessels 2019; 35:207-213. [DOI: 10.1007/s00380-019-01474-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
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13
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Driveline Site Is Not a Predictor of Infection After Ventricular Assist Device Implantation. ASAIO J 2019; 64:616-622. [PMID: 29035899 DOI: 10.1097/mat.0000000000000690] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term ventricular assist device (VAD) support. We aimed to assess whether VAD driveline exit site (DLES) (abdomen versus chest wall) is associated with DLI. All adult patients who underwent insertion of a HeartWare HVAD or HeartMate II (HMII) between 2009 and 2016 were included. Driveline infection was defined as clinical evidence of DLI accompanied by a positive bacterial swab and need for antibiotics. Competing risks analysis was used to assess the association between patient characteristics and DLI. Ninety-two devices (59 HMII) were implanted in 85 patients (72 men; median age 57.4 years) for bridge to transplant or destination therapy. VAD DLES was chest in 28 (30.4%) devices. Median time on VAD support was 347.5 days (IQR 145.5, 757.5), with 28 transplants and 29 deaths (27 on device). DLI occurred in 24 patients (25 devices) at a median of 140 days (IQR 67, 314) from implant. Staphylococcus aureus accounted for 15 infections (60%). Freedom from infection was 72.8% (95% confidence interval [CI] 53.1-78.0%) at 1 year and 41.9% (95% CI 21.1-61.5%) at 3 years. In competing risks regression, abdominal DLES was not predictive of DLI (hazard ratio, HR 1.65 [95% CI 0.63, 4.29]), but body mass index (BMI) >30 kg/m was (HR 2.72 [95% CI 1.25, 5.92]). In conclusion, risk of DLI is high among patients on long-term VAD support, and a nonabdominal DLES does not reduce this risk. The only predictor of DLI in this series was an elevated BMI.
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14
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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: 37] [Impact Index Per Article: 6.2] [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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15
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Driveline angle is crucial for preventing driveline infection in patients with HeartMate II device. J Artif Organs 2018; 22:37-43. [DOI: 10.1007/s10047-018-1074-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/02/2018] [Indexed: 12/20/2022]
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16
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Yoshitake S, Kinoshita O, Nawata K, Hoshino Y, Itoda Y, Kimura M, Yamauchi H, Ono M. Novel driveline route for prevention from driveline infection: Triple tunnel method. J Cardiol 2018; 72:363-366. [PMID: 29731190 DOI: 10.1016/j.jjcc.2018.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The most prevalent and serious infection related to left ventricular assist devices (LVADs) is driveline infection (DLI). From 2014, we employed a revised surgical technique (triple tunnel method), which deployed a longer subfascial driveline (DL) route. METHODS AND PATIENTS We retrospectively analyzed 34 patients fitted with either of the two types of axial pumps: HeartMate II (n=23) and Jarvik 2000 (n=11). Prior to 2014, the DL proceeded from the pump pocket just above the posterior sheath of the rectus muscle toward a vertical skin incision at the right lateral border of the rectus muscle. Then, DL was turned leftward into the subcutaneous tissue to redirect its exit to the left side [subcutaneous tissue group (Group S): n=14]. From 2014, we made an additional skin incision below the umbilicus with the aim of lengthening the subfascial DL route [muscle group (Group M): n=20]. RESULTS DLI occurred in 10 patients (71.4%) in Group S and in 1 patient (5%) in Group M (p<0.05, Chi-square test). The freedom rate from re-admission at 1 year due to DLI was 64% in Group S and 95% in Group M, respectively (p=0.021, log-rank test). Furthermore, logistic regression analysis revealed that DL route was significantly associated with DLI (odds ratio, 10.1; 95% confidence interval, 1.15-275.3). CONCLUSION Although a longer follow-up period will be needed, the triple tunnel method may be beneficial in the prevention of DLI.
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Affiliation(s)
- Shuichi Yoshitake
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan.
| | - Osamu Kinoshita
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Kan Nawata
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Yasuhiro Hoshino
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Yoshifumi Itoda
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan.
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Journal of Artificial Organs 2017: the year in review : Journal of Artificial Organs Editorial Committee. J Artif Organs 2018; 21:1-7. [PMID: 29426998 PMCID: PMC7102331 DOI: 10.1007/s10047-018-1018-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Indexed: 02/06/2023]
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18
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Nishida M. Artificial hearts-recent progress: republication of the article published in the Japanese Journal of Artificial Organs. J Artif Organs 2017; 20:187-193. [PMID: 28620709 DOI: 10.1007/s10047-017-0969-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 06/06/2017] [Indexed: 11/30/2022]
Abstract
This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2015 (Vol.44, No. 3, pp.130-135), with some modifications regarding several references published in 2015 or later.
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Affiliation(s)
- Masahiro Nishida
- Artificial Organ Research Group, Health Research Institute, National Institute of Advanced Industrial Science and Technology, 1-2-1 Namiki, Tsukuba, Ibaraki, 305-8564, Japan.
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