An ISHLT consensus document for prevention and management strategies for mechanical circulatory support infection

Epidemiology and impact of device-specific infections on patients receiving left ventricular assist devices

Background

Left ventricular assist device-specific infections (LSIs) remain a persistent problem facing patients with durable left-ventricular assist devices (LVADs). However, the infectious agents and associated morbidity remained poorly defined. We sought to evaluate the incidence, epidemiology, and morbidity associated with LSIs in patients receiving modern centrifugal LVADs at 2 tertiary care centers.

Methods

Retrospective analysis was performed of adult patients receiving HeartMate 3 implants at the University of Pennsylvania and Mount Sinai Health Systems from January 1, 2015 to March 31, 2021, with follow-up until March 31, 2022. Patients were grouped by history of LSI, defined as culture-positive infections and/or those requiring medical or surgical intervention. Demographic data, available culture data, medical interventions, and surgical interventions were queried. Survival analysis was censored at 4 years and landmarked according to 25th percentile time-to-infection.

Results

Among 206 LVAD recipients, 71 (34.5%) developed an LSI. Predominant organisms were Staphylococcus (47.9%), Pseudomonas (15.5%), and Serratia (8.5%). Predictors of infection included Black race (LSI vs No LSI: 46.2% vs 29.2%, p = 0.021) and body mass index (median 29.7 vs 26.2 kg/m2, p = 0.007). Median time to infection was 231 days (112-423), with 19 (26.8%) patients requiring surgical debridement. Landmarked survival did not differ (log-rank p = 0.830). LSI patients were hospitalized an extra 8 (0-28) days for infection-related reasons.

Conclusion

LSIs remain pervasive, with most related to Staphylococcus, Pseudomonas, and Serratia, and are associated with significantly increased rehospitalization burden. Surgical interventions were utilized in 26.8% of patients. Continued efforts to understand and prevent LSIs are necessary to improve care for LVAD patients.

Omentoplasty for ventricular assist device infections: Encouraging outcomes

Background

LVAD infections are associated with substantial morbidity and mortality. We explored the impact of surgical Omentoplasty (OMP) added to Incision and Debridement (I&D) plus Antibiotic therapy (AB) on survival and infection-related readmissions in patients with LVAD infections.

Methods

Thirty-three patients with deep LVAD-specific infections were studied over a period of 12 years. Survival and readmissions for recurrent infection in subjects receiving I&D and ABs alone (Group A, n = 15) were compared to those in whom OMP was added to I&D and ABs (Group B, n = 18).

Results

Baseline characteristics were similar between groups, as well as infectious organisms. Two-year survival was significantly improved in Group B (OMP + I&D + ABs) as compared to Group A (I&D + ABs without OMP) [77% vs. 7%; p < 0.001]. Recurrent infection-related readmissions were notably lower in Group B compared to Group A (0.18 vs. 0.24 admissions/patient-year), with a significant reduction within Group B following the application of OMP (0.13 to 0.06 admissions/patient-year). Following OMP, intravenous (IV) antibiotics were successfully replaced with oral long-term ABs in the 78% of patients. No long-term antibiotic-related complications were noted.

Conclusion

This report, comprising the most extensive such experience to date, indicates that combining surgical Omentoplasty (OMP) with incision and debridement (I&D) plus antibiotic (AB) treatment is remarkably effective for suppressing deep LVAD infections, improving survival and decreasing infection-related readmissions. Filling the open space around an implanted LVAD with highly vascularized omentum, as a living tissue with anti-infective properties, appears to be effective for improving outcomes with LVAD infections.

Targeting Chronic Biofilm Infections With Patient-derived Phages: An In Vitro and Ex Vivo Proof-of-concept Study in Patients With Left Ventricular Assist Devices

Background

Phage therapy is being reconsidered as a valuable approach to combat antimicrobial resistance. We recently established a personalized phage therapy pipeline in healthy volunteers, where therapeutic phages were isolated from individuals' skin microbiota. In this study, we aim to validate this pipeline in end-stage heart failure patients supported by left ventricular assist devices (LVADs), focusing on phages targeting Staphylococcus epidermidis, a common pathogen responsible for LVAD infections.

Methods

Over a 2.5-year period, 45 LVAD patients were consistently sampled at their driveline exit sites and foreheads. S epidermidis strains from patients' foreheads were used to amplify patient-specific phages. Newly isolated phages were characterized and tested against S epidermidis isolates (n = 42) from the patient cohort. The virulent phage vB_SepS_BE22, isolated from a patient with a driveline infection, was further tested for its bactericidal activity against S epidermidis biofilms ex vivo with rifampicin on driveline biofilms.

Results

S epidermidis was detected in 32 patients, 3 of whom had driveline infections. Phages were isolated from 8 patients, 6 of which were unique and exhibited narrow host ranges, infecting 19%-52% of S epidermidis strains. vB_SepS_BE22, isolated from patient ID25's microbiota, was the only phage that specifically killed S epidermidis clones linked to a patient's infection. vB_SepS_BE22 also reduced bacterial loads in exponential and stationary phase cultures, as well as in biofilms on drivelines when combined with rifampicin.

Conclusions

This study validated a personalized phage therapy approach, where phages from a patient's own microbiota can be used in chronic infection settings as therapeutic agents.

A consensus-based framework for the psychosocial evaluation of pediatric candidates for cardiothoracic transplant and ventricular assist devices

The psychosocial evaluation plays an essential role in the multidisciplinary assessment of pediatric patients for thoracic organ transplantation or ventricular assist device (VAD) placement. However, there is considerable practice variation with regard to the content and process of the evaluation, with no known recent published guidelines. Furthermore, the pediatric evaluation necessarily differs from the adult evaluation in a number of substantive ways, including caregiver roles and decision-making. A writing committee of 25 multidisciplinary experts in pediatric cardiothoracic transplantation/VAD was established, who conducted a comprehensive literature review which resulted in the development of this consensus-based framework. This framework, which is a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT), the International Pediatric Transplant Association (IPTA), the Pediatric Heart Transplant Society (PHTS), the Advancing Cardiac Therapies Improving Outcomes Network (ACTION), and Transplant Families, represents the first known framework specific to both the content and process of the psychosocial evaluation for pediatric cardiothoracic transplantation/VAD. Attention was paid to relevant ethical, cultural and health equity considerations inherent in the pediatric evaluation process. Rather than provide a proscriptive evaluation process, the goal was to create a flexible framework to encourage consistency across centers, while also acknowledging the complexities inherent in evaluating children and their families for cardiothoracic transplant and VAD.

Prospective evaluation of the Moleculight i:X™ in the early detection of driveline infections

OBJECTIVES

Driveline infection (DLI) is a common complication in patients with left ventricular assist devices. This complication can seriously undermine quality of life while on left ventricular assist devices. Current diagnosis of a DLI in the outpatient setting is based on clinical examination and later bacteria isolation. The Moleculight i:XTM is a handheld fluorescence imaging device capable to visualize bacterial colonization in real-time. We here evaluated the performance of the Moleculight i:XTM for diagnosis of DLIs as this device may have the potential advantage to rapidly identify infection and therefore promptly influence therapy.

METHODS

A total of 107 examinations in patients with suspected DLIs were prospectively included in this study. All examinations took place in the outpatient setting. In addition to the standard treatment, Moleculight fluorescence images were captured and swabs were taken at the area of maximal luminosity. Wounds and pictures were reviewed and classified as positive or negative by a wound specialist and two heart surgeons independently from microbiological results.

RESULTS

The Moleculight i:XTM showed positive results (red fluorescence) in 19 cases (17.76%), whereas microbiological examination was positive for microorganisms in 74 cases (69.16%). The most common bacteria was Staphylococcus aureus. The findings resulted in a sensitivity of 13.51% and a specificity of 72.73%. The positive predictive value was 52.63% and the negative predictive value was 27.27%. Sub-analyses of different wound dressings or previous antibiotic treatment did not show any relevant difference.

CONCLUSIONS

The results of the Moleculight i:X show a low sensitivity and specificity when being used to detect DLIs in the outpatient setting. Clinical examination and swabs should remain the gold standard despite the delay for bacteria isolation and consequent antibiotic treatment. Sensitivity and specificity of the Moleculight i:X in open wounds after surgical revision of the driveline remain to be clarified.

Clinical Outcomes of Left Ventricular Assist Device Bleeding Complication

Bleeding complications have emerged as major causes of morbidity and mortality in patients with implantable left ventricular assist devices (LVAD). We hypothesized that the hemodynamics after LVAD implantation may influence the occurrence of bleeding complications after LVAD implantation. We retrospectively evaluated 78 patients who underwent continuous-flow LVAD implantation and hemodynamic ramp test after LVAD implantation between July 2017 and July 2023 at Osaka University. The bleeding complication occurred in 13 patients. The rates of freedom from bleeding complications at 1, 3, and 5 years were 94%, 85%, and 74%. Gastrointestinal bleeding, nose bleeding, and intraperitoneal hemorrhage occurred in six, three, and two patients, respectively. Preoperative average brachial-ankle pulse wave velocity (baPWV) was positively associated with bleeding complication (1,276 ± 280 vs . 1,098 ± 190 cm/s p = 0.04). In the hemodynamic ramp test, systemic vascular resistance (SVR) in patients with bleeding complications was higher than that in patients without bleeding complications (SVR: 1,359 ± 341 vs. 1,150 ± 217 dyne sec/cm 5 , p = 0.01). High preoperative baPWV and high SVR in the hemodynamic ramp test were significantly associated with bleeding complications after LVAD implantation. Arteriosclerosis is a risk factor for bleeding complications after LVAD implantation.

Infection epidemiology, preventive measures and principles of best practices involving the skin and dressing of patients with a ventricular assist device: A scoping review

BACKGROUND

Specific knowledge of several domains for managing care in the driveline externalization area may be necessary for the broader application of left ventricular assist devices.

OBJECTIVES

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

DESIGN

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

METHOD

Left ventricular assist device coordinators and nurse specialists in dermatology and stomatherapy conducted a scoping review limited to the period between 2015 and 2022. The results of this scoping review will be discussed and presented separately in 3 articles. This third article synthesizes research evidence on the epidemiology of device infections, infection preventive measures, local skin care and dressings in adult patients with left ventricular assist devices.

RESULTS

The initial search resulted in 771 studies. Sixty nine met the eligibility criteria and were included in the scoping review. Eighteen articles addressing the epidemiology of device infections, infection preventive measures, and local skin and dressing care that answered the question of this article were included. The most common bacterial pathogens reported have been Gram-positive bacteria, typically Staphylococcus species. With respect to infection preventive measures, there are evidence gaps in local skin care and transmission system dressings.

CONCLUSION

The driveline still remains the most common type of device infection. There exists imperfect knowledge on the standardization of care with the dressing and the area of skin for left ventricular assist device patients. Furthermore, there is a methodological fragility of the studies. These elements imply an opportunity for future research on these subjects.

IMPLICATIONS FOR CLINICAL PRACTICE

This review provides an overview of the principles of best practices involving the skin and dressing of patients with a ventricular assist device without local dermatological diseases or infectious diseases. The central figure of an experienced professional can make a difference.

Cold atmospheric plasma therapy as a novel treatment for Berlin Heart EXCOR pediatric cannula infections

BACKGROUND

Cold atmospheric plasma (CAP) therapy has been recognized as effective treatment option for reducing bacterial load in chronic wounds, such as adult ventricular assist device (VAD) driveline exit-site infections. Currently, there have been no reports on the safety and efficacy of CAP therapy for pediatric cannula infections and inflammations in paracorporeal pulsatile VADs.

METHODS

The mechanical strength of Berlin Heart EXCOR cannulas were tested both before and after CAP treatment (SteriPlas, Adtec Healthcare Limited, UK) to prove material safety. A ring tensile test of 20 untreated and 20 CAP-treated (5 min) EXCOR cannulas (Ø12mm), assessed the force at the breaking point of the cannulas (Fmax), at 25% (F25%) and 50% (F50%) of the maximum displacement. Additionally, the scanning electron microscope (SEM) micrographs for both groups examined any surface changes. Finally, the case of a 13-year-old male EXCOR patient with cannula infections, treated with CAP over 100 days, is presented.

RESULTS

The in vitro measurements revealed no statistically significant differences in mechanical strength between the control and CAP group for F25% (8.18 ± 0.36 N, vs. 8.02 ± 0.43 N, p = 0.21), F50% (16.87 ± 1.07 N vs. 16.38 ± 1.32 N, p = 0.21), and FMAX (44.55 ± 3.24 N vs. 42.83 ± 4.32 N, p = 0.16). No surface structure alterations were identified in the SEM micrographs. The patient's cannula exit-sites showed a visible improvement in DESTINE wound staging, reduction in bacterial load and inflammatory parameters after CAP treatment without any side effects.

CONCLUSION

Overall, CAP therapy proved to be a safe and effective for treating EXCOR cannula exit-site wound healing disorders in one pediatric patient, but further studies should investigate this therapy in more detail.

Detection of Gram-Ghost Bacilli and Additional Ziehl-Neelsen Stain for the Early Diagnosis of Driveline Infection: A Case Report

BACKGROUND

Driveline infections (DLI) caused by nontuberculous mycobacteria (NTM) in patients with implantable left ventricular assist devices (iLVAD) are rare but fatal, requiring early diagnosis and appropriate treatment. Herein, we present a rare case of DLI caused by Mycobacterium chelonae, which was promptly diagnosed using Gram stain and Ziehl-Neelsen stain and followed a favorable clinical course.

CASE PRESENTATION

A 51-year-old man with an iLVAD complicated by DLI was admitted to our center. He had no fever but had a slight ache and rash around the driveline exit site on admission. The wound condition gradually deteriorated with increasing purulent discharge from the driveline exit site and an elevated inflammatory response, despite daily irrigation. Gallium scintigraphy led to the diagnosis of deep DLI, followed by surgical debridement and omental flap transposition with driveline translocation. The Gram stain of the purulent discharge from the surgical site showed unstained bacilli (Gram-neutral, neither positive nor negative) along with leukocyte phagocytosis. Additionally, the Ziehl-Neelsen stain was positive. NTM was suspected after confirming the negative polymerase chain reaction for M. tuberculosis. Antibiotic therapy was switched to a specific regimen for skin and soft tissue infections caused by NTM. After identifying M. chelonae, antibiotic therapy was switched to a more specific regimen (clarithromycin and doxycycline) for M. chelonae according to the susceptibility test results. The patient was discharged after 3 months without infection recurrence.

CONCLUSIONS

Detecting Gram-ghost bacilli and using an additional Ziehl-Neelsen stain can be beneficial for the early diagnosis of repeated DLI with unknown etiology.

Clinical outcomes of modified left ventricular assist device driveline management

Left ventricular assist devices (LVADs) are implanted in patients with heart failure to support cardiac circulation. However, no standardized methods have been established for LVAD driveline exit site management for the prevention of infections. Therefore, this study evaluated the efficacy of modified driveline management compared with that of conventional driveline management. We retrospectively assessed the outcomes of 262 patients who underwent continuous-flow LVAD implantation between January 2005 and March 2023 at Osaka University in Japan. In conventional driveline management, an LVAD driveline penetrates the skin along the body surface and is fixed near the penetration site (n = 224). In contrast, in our modified fixation method, the LVAD driveline vertically penetrates the skin to prevent ischemia at the driveline exit site and is fixed at a distant abdominal site to prevent the movement of the driveline exit site due to body movement (n = 38). The rates of freedom from LVAD driveline infection in patients with conventional driveline management were 86, 75, and 63% at 1, 2, and 3 years after LVAD implantation, respectively. The rate of freedom from LVAD driveline infection in patients managed by the modified fixation method was 91% at 1, 2, as well as 3 years after LVAD implantation. The freedom rates from LVAD driveline infection in the patients with modified fixation method was lower than in the patients with the conventional method (p = 0.04). Our study revealed that the modified fixation method may offer the possibility for preventing LVAD driveline infection.

Infections in Patients with Mechanical Circulatory Support

Patients on mechanical circulatory support are at heightened risk for infection given the invasive nature of the devices with internal and external components, the surgical implantation of the devices, and the presence of foreign material susceptible to biofilm formation. This review discusses the new International Society for Heart and Lung Transplantation mechanical circulatory support device infection definitions, inclusive of durable and acute mechanical circulatory support infections, and describes their epidemiology, diagnosis, and management. A multidisciplinary approach is essential for optimal management. Timing of transplantation in the context of active infection is addressed, and areas of future research are highlighted.

Outcome Through the Years of Left-Ventricular Assist Devices Therapy for End-Stage Heart Failure: A Review

Heart transplantation remains the gold standard surgical treatment for advanced heart failure. Over time, medical therapies have achieved remarkable outcomes in terms of survival and quality of life, yet their results may be insufficient, even when maximized. The limited availability of organ donors and the selective criteria for heart transplant eligibility have led to a significant rise in the utilization of long-term mechanical circulatory support, including left ventricular assist devices. Patients receiving LVADs often present with multiple comorbidities, constituting a highly vulnerable population. Individuals living with LVADs may experience various long-term complications, such as bleeding, driveline infections, neurological events, and right ventricular dysfunction. Fortunately, the development of increasingly biocompatible LVAD devices in recent years has resulted in a notable reduction in these complications. This review aims to summarize the principal complications encountered by patients with LVADs throughout their treatment and the associated daily management strategies.

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

The Predictive Role of Metabolic Volume Segmentation Compared to Semiquantitative PET Parameters in Diagnosis of LVAD Infection using [18F]FDG Imaging

PURPOSE

Left ventricular assisting device (LVAD) is a vital mechanical circulatory assist device for patients with end-stage heart disease, serving as either a bridge to transplantation or palliative destination therapy. Yet device infection represents a major lethal complication, warranting a multi-step, complex therapy approach including an urgent device exchange or heart transplantation. Still, timely diagnosis of site and extent of VAD-specific infection for a proper therapy planning poses challenges in regular clinical care. This single-center, retrospective study aimed to evaluate the impact of volumetric PET parameters with different thresholding compared to semiquantitative PET parameters for accurate diagnosis of VAD-specific infection.

PROCEDURES

Seventeen patients (1 female, 16 males; mean age 57 ± 11 years) underwent [18F]FDG imaging for suspected VAD-specific infection between April 2013 and October 2023. Various metabolic and volumetric PET parameters with different thresholding were collected for specific LVAD components including driveline entry point, subcutaneous driveline, pump pocket, inner cannula and outflow tract. Microbiology and clinical follow-up were used as the final diagnosis standard.

RESULTS

Nine of eleven patients with VAD-specific infection underwent urgent heart transplantation, and one had a surgical revision of LVAD. Two patients had non-VAD specific infections, and two had non-VAD related infections. Metabolic burden determination using a fixed absolute threshold provided the best outcome compared to relative thresholding or other metabolic SUV parameters. The total metabolic tumor volume (MTV) cutoff value was 9.3 cm3, and the corresponding sensitivity, specificity, accuracy, and AUC were 90.0%, 71.43%, 82.5%, and 0.814 (95% CI 0.555-0.958), respectively. The total lesion glycolysis (TLG) was 30.6, and the corresponding sensitivity, specificity, accuracy, and AUC were 90.0%, 71.4%, 82.5%, and 0.829 (95% CI 0.571-0.964), respectively.

CONCLUSIONS

Volumetric PET parameters with fixed absolute thresholding appear to be a valuable auxiliary tool in the evaluation of [18F]FDG imaging to enhance the diagnostic accuracy of VAD-specific infection.

Risk factors, diagnostic methods and treatment of infection in adult patients undergoing left ventricular assist device implantation: A scoping review

BACKGROUND

Evidence on infection risk factors is scarce, and precise localization of the site of infection and its treatment remain clinically challenging.

OBJECTIVES

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

DESIGN

This is a scoping review, registered in the Open Science Framework under DOI10.17605/OSF.IO/Q76B3(https://osf.io/q76b3/).

METHOD

This is a scoping review limited to the period between 2015 and 2022.The results of this scoping review are discussed and presented separately in 3 articles. This second paper synthesizes research evidence on the risk factors, diagnostic methods and treatment of infection in adult patients undergoing left ventricular assist device implantation.

RESULTS

The initial searches identified 771 studies. Sixty-nine patients met the eligibility criteria and were included in the scoping review. Forty-three articles addressing the risk factors, diagnosis and treatment of infection were included to answer the questions of this review.

CONCLUSION

Obesity has been shown to be the most common risk factor for the described process of infection by left ventricular assist devices.18F-fluorodeoxyglucose positron emission tomography showed high sensitivity in detecting cardiac device infection, and labeled leukocyte or gallium citrate-67 scintigraphy showed high specificity for left ventricular assist device infections; therefore, it can help differentiate infection from inflammation, particularly in patients with equivocal fluorodeoxyglucose positron emission tomography. Also, this review brings and discusses the limitations and strengths of diagnostic tests, the knowledge regarding the risk factors for left ventricular assist device infection, the therapeutic heterogeneity, the methodological issues of the studies, and the vast opportunity for future research on left ventricular assist device.

IMPLICATIONS FOR CLINICAL PRACTICE

Ventricular assist device professionals should evaluate risk factors prior to device implantation and periodically.18F-fluorodeoxyglucose positron emission tomography should be considered as diagnostic tool in detecting superficial and deep driveline infections. Early treatment, including chronic suppressive therapy and serial surgical debridement, combined with driveline exteriorization and delayed driveline relocation may constitute a potential therapeutic strategy for deep driveline infections.

Clinical characteristics and short-term outcomes in patients with cardiogenic shock undergoing mechanical circulatory support escalation from intra-aortic balloon pump to impella: From the J-PVAD registry

BACKGROUND

An escalation strategy from intra-aortic balloon pump (IABP) to Impella (AbioMed, Danvers, MA, USA) is proposed in patients with cardiogenic shock (CS) refractory to IABP therapy, but its clinical data are lacking. This study aimed to elucidate the clinical characteristics and short-term outcomes in patients undergoing IABP-Impella escalation.

METHODS AND RESULTS

From the Japanese nationwide registry of Impella (J-PVAD), a total of 2578 patients with CS receiving Impella support were classified into the IABP-Impella group (n = 189) or the Primary Impella group (n = 2389). We applied 1:3 propensity score (PS) matching, selecting 185 patients and 555 patients, respectively. Before matching, the IABP-Impella group presented longer shock-to-Impella time, worse laboratory data, and more frequent inotropes and pulmonary artery catheter use than the Primary Impella group. After matching, the baseline characteristics were well-balanced. Regarding the 30-day clinical outcomes in the PS-matched cohort, there were no significant differences in the rates of mortality and major complications (a composite of bleeding, hemolysis, infection, stroke, myocardial infarction, limb ischemia, and vascular injury) between the groups. However, The IABP-Impella group showed a significantly higher rate of infection (10.3 % vs. 5.6 %, p = 0.042) and additional mechanical circulatory support use (34.1 % vs. 23.8 %, p = 0.008) than the Primary Impella group.

CONCLUSIONS

Compared to patients with primary Impella support, those undergoing IABP-Impella escalation showed similar 30-day mortality and major complications despite poorer clinical conditions before Impella support and a more complicated clinical course after Impella insertion.

Patient management important for long-term support beyond 5 years in the BTT: republication of the article published in the Japanese Journal of Artificial Organs

Heart transplantation is considered to be the best treatment for severe heart failure refractory to medical therapy, improving patients' survival and quality of life (QOL). However, the number of donors is smaller than the number of registered applicants for heart transplantation, which increases every year, and the waiting period for heart transplantation has been extended to more than 1700 days by 2022. Since 2011, reimbursement for the implantable left ventricular assist device (iLVAD) was established. The numbers of the iLVAD patients have been increasing year by year. Patients are managed at home with an iLVAD and can live with their families and even return to work, depending on the situation. On the other hand, self-management at home, including caregivers, is important for a safe life. Home management beyond 5 years is becoming more common due to long waiting time for transplant. This article outlines the important aspects of patient management for long-term support. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 62-66), with some modifications.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

METHOD

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR CLINICAL PRACTICE

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

18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations From ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multisocietal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multifocal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Management of infectious disease syndromes in thoracic organ transplants and mechanical circulatory device recipients: a Delphi panel

PURPOSE

Antimicrobial misuse contributes to antimicrobial resistance in thoracic transplant (TTx) and mechanical circulatory support (MCS) recipients. This study uses a modified Delphi method to define the expected appropriate antimicrobial prescribing for the common clinical scenarios encountered in TTx and MCS recipients.

METHODS

An online questionnaire on managing 10 common infectious disease syndromes was submitted to a multidisciplinary Delphi panel of 25 experts from various disciplines. Consensus was predefined as 80% agreement for each question. Questions where consensus was not achieved were discussed during live virtual live sessions adapted by an independent process expert.

RESULTS

An online survey of 62 questions related to 10 infectious disease syndromes was submitted to the Delphi panel. In the first round of the online questionnaire, consensus on antimicrobial management was reached by 6.5% (4/62). In Round 2 online live discussion, the remaining 58 questions were discussed among the Delphi Panel members using a virtual meeting platform. Consensus was reached among 62% (36/58) of questions. Agreement was not reached regarding the antimicrobial management of the following six clinical syndromes: (1) Burkholderia cepacia pneumonia (duration of therapy); (2) Mycobacterium abscessus (intra-operative antimicrobials); (3) invasive aspergillosis (treatment of culture-negative but positive BAL galactomannan) (duration of therapy); (4) respiratory syncytial virus (duration of antiviral therapy); (5) left ventricular assist device deep infection (initial empirical antimicrobial coverage) and (6) CMV (duration of secondary prophylaxis).

CONCLUSION

This Delphi panel developed consensus-based recommendations for 10 infectious clinical syndromes seen in TTx and MCS recipients.

Absorbable antibiotic beads for treatment of LVAD driveline infections

BACKGOUND

Infections of the left ventricular assist device (LVAD) driveline are a dreaded complication that results in high mortality and morbidity.

METHOD

We retrospectively reviewed five consecutive patients with severe continuous-flow LVAD (HVAD, Heartmate 2, and Heartmate 3) driveline infection. These infections, which developed on an average of 960.4 ± 843.9 days after LVAD placement, were refractory to systemic antibiotics and local wound care. All were treated with extensive surgical debridement, local installation of absorbable antibiotic-loaded calcium sulfate beads (vancomycin and tobramycin), primary wound closure, and 6 weeks of systemic antibiotics after surgery.

RESULTS

Four patients had resolution of DLI, and one had a recurrent infection at another part of the driveline 7 months after the complete resolution of the previous site. This patient was successfully treated with debridement and bead placements. Three patients still have their LVADs, while two received orthotopic heart transplants. At the time of the transplant, there was no evidence of gross infection of the LVAD drivelines or pumps. At the average follow-up time of 425.8 ± 151 days, no patients have an active infection.

CONCLUSION

Treatment of LVAD driveline infection with absorbable antibiotic beads with primary wound closure is a viable option and merits further investigation.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Repeat left ventricular-assisted device exchange and upgrade from second- to third-generation devices in a high-volume single center

BACKGROUND

Pump exchange is an established strategy to treat LVAD-related complications such as thrombosis, infection, and driveline failure. Pump upgrades with an exchange to newer generation devices are being performed to the advantage of the patient on long-term support. The safety and efficacy of a repeat LVAD exchange with a concomitant upgrade to a third-generation pump have not been reported.

METHODS

We performed a retrospective analysis of all consecutive patients who underwent a repeat LVAD device exchange and upgrade to HeartMate III (HMIII) at Houston Methodist Hospital between December 2018 and December 2020.

RESULTS

Five patients underwent exchange and upgrade to HMIII within the specified timeframe. Four patients had already had two prior exchanges (all HMII to HMII), and one patient had one prior exchange (HVAD to HVAD). In all cases, implantation was performed as destination therapy. The surgical exchange was performed via redo median sternotomy on full cardiopulmonary bypass. No unplanned redo surgery of the device component was required. In-hospital mortality was 20% in this very high-risk population. At 1-, 3-, and 6-month follow-up, all discharged patients were on HMIII support, with no major LVAD-related adverse events reported.

CONCLUSION

We report the feasibility and safety of a repeat pump exchange with an upgrade to HMIII in a high-volume center. The decision for medical therapy versus surgical exchange has to be tailored to individual cases based on risk factors and clinical stability but in expert hands, even a re-redo surgical approach grants options for good medium-term outcomes.

Mechanical Characterization of Anchoring Devices for the Prevention of Driveline Infection in Left Ventricular Assist Device Patients

Driveline infection (DLI) is associated with increased mortality and morbidity in left ventricular assist device (LVAD) patients. Because trauma to the driveline exit-site (DLES) is a risk factor for DLI, adhesive anchoring devices are used to immobilize the DL. In this study, commonly used products (identified through literature review and contact with nine international VAD implantation centers) were mechanically characterized to evaluate their effectiveness in preventing DLES trauma. Eight devices were tested in an in vitro abdominal model of the DLES, where a tensile force (10 N) was applied to a HeartMate 3 DL, whereas the resulting force ( FTotal ) on the DLES was recorded using a three-axis load cell. Four devices (CathGrip: FTotal = 2.1 ± 0.4 N, Secutape: FTotal = 2.6 ± 0.3 N, Hollister: FTotal = 2.7 ± 0.5 N, Tubimed: FTotal = 2.9 ± 0.2 N) were significantly ( p < 0.05) better at preventing tensile forces at the DLES compared to the other four devices (Main-Lock: FTotal = 3.7 [0.7] N, Secutape sensitive: FTotal = 3.9 ± 0.4 N, Foley Anchor: FTotal = 4.3 ± 0.5 N, Grip-Lok: FTotal = 5.4 ± 0.8 N). Immobilization of the DL with each anchoring device resulted in lower tensile force on the DLES than without an anchor ( FTotal = 8.2 ± 0.3 N). In conclusion, the appropriate selection of anchoring devices plays a critical role in reducing the risk of DLI, whereas the CathGrip, Secutape, Hollister, or Tubimed were superior in preventing trauma to the DLES in this study.

Left ventricular assist device-associated driveline infections as a specific form of complicated skin and soft tissue infection/acute bacterial skin and skin structure infection - issues and therapeutic options

PURPOSE OF REVIEW

This review comments on the current guidelines for the treatment of wound infections under definition of acute bacterial skin and skin structure infections (ABSSSI). However, wound infections around a catheter, such as driveline infections of a left ventricular assist device (LVAD) are not specifically listed under this definition in any of the existing guidelines.

RECENT FINDINGS

Definitions and classification of LVAD infections may vary across countries, and the existing guidelines and recommendations may not be equally interpreted among physicians, making it unclear if these infections can be considered as ABSSSI. Consequently, the use of certain antibiotics that are approved for ABSSSI may be considered as 'off-label' for LVAD infections, leading to rejection of reimbursement applications in some countries, affecting treatment strategies, and hence, patients' outcomes. However, we believe driveline exit site infections related to LVAD can be included within the ABSSSI definition.

SUMMARY

We argue that driveline infections meet the criteria for ABSSSI which would enlarge the 'on-label' antibiotic armamentarium for treating these severe infections, thereby improving the patients' quality of life.

Anesthetic management for non-cardiac surgery in patients with left ventricular assist devices

With the growing number of patients undergoing left ventricular assist device (LVAD) implantation and improved survival in this population, more patients with LVADs are presenting for various types of non-cardiac surgery. Therefore, anesthesiologists need to understand the physiology and adequately prepare for the perioperative management of this unique patient population. This review addresses perioperative considerations and intraoperative management for the safe and successful management of patients with an LVAD undergoing non-cardiac surgery. Understanding the basic physiology of preload dependency and afterload sensitivity in these patients is essential. The main considerations include a collaborative preoperative multidisciplinary approach, perioperative care aimed at optimizing the intravascular volume and right ventricular function, and maintaining the afterload within recommended ranges for optimal LVAD function.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Theory of Pivoting Uncertainties: Advance Care Planning Among Individuals Living With Mechanical Circulatory Support

BACKGROUND

Individuals living with mechanical circulatory support (MCS) devices are confronted with risks for catastrophic outcomes such as stroke and systemic infection. Considering these complexities, ongoing advance care planning (ACP) is important for shared decision making.

OBJECTIVE

The purpose of this study was to describe how experiences of the MCS trajectory informed decision making about ACP.

METHODS

All aspects of the research were guided by constructivist grounded theory. Focused conversations were conducted with a semistructured interview guide.

RESULTS

A total of 24 community-dwelling patients living with MCS were interviewed (33% female; mean age, 60.6 years; 50% White). Participants were implanted with MCS (average duration, 29.8 months; bridge to transplant, 58%). Reflected in the narratives were tensions between initial expectations of living with the device in contrast with the realities that emerged over time. A crucial finding was that ACP decision making pivoted around the growing awareness of uncertainties in the MCS trajectory. Yet, clinicians were perceived to be silent in initiating ACP, and their reticence was understood as a sign of encouragement to hold on to hope for a heart transplant. The complex and dynamic decision-making processes around ACP were organized into the theory of pivoting uncertainties.

CONCLUSIONS

In this sample, patients were ready to share their concerns about the uncertainties of living with MCS and waited for MCS clinicians to initiate ACP. The theory of pivoting uncertainties is useful for elucidating the ebb and flow of ACP and lending clinicians' guidance for opportunities to initiate these sensitive conversations.

Bloodstream infections in prolonged use of axillary-placed, intra-aortic balloon-pump support: A single-center study

Infections from prolonged use of axillary intra-aortic balloon pumps (IABPs) have not been well studied. Bloodstream infection (BSI) occurred in 13% of our patients; however, no difference in outcome was noted between those with BSI and those without. Further studies regarding protocol developments that minimize BSI risk are needed.

Delayed sternal Mycobacterium tuberculosis infection after left ventricular assist device implantation: A case report

The incidence of Mycobacterium tuberculosis (Mtb) infection in patients with mechanical circulatory support devices is extremely rare. We present a case involving a 38-year-old male who experienced a delayed sternal Mtb infection following left ventricular assist device (LVAD) implantation. More than 5 months post-surgery, the patient was readmitted to the hospital presenting a subxiphoid abscess. The incision site displayed an unsatisfactory healing process after the incision and drainage of the abscess. Despite engaging in a rigorous treatment protocol, which included anti-infective therapy, vacuum-assisted closure, and surgical debridement, the patient's wound remained unhealed. Ultimately, after pus gene sequencing confirmed the diagnosis, the patient was administered a regimen combining anti-tuberculosis and anti-infective therapy, which culminated in the successful healing of the wound. This singular case study not only reveals the clinical progression of an unexpected Mtb infection post-implantation but also emphasizes the challenges encountered in diagnosis and management.

Driveline infections in left ventricular assist devices-Incidence, epidemiology, and staging proposal

BACKGROUND

Driveline infections (DLI) are a serious complication in patients with left ventricular assist devices (LVAD). Apart from the differentiation between superficial and deep DLI, there is no consensus on the classification of the severity of DLI. Little is known about risk factors and typical bacteria causing DLI in centrifugal-flow LVADs.

METHODS

In this single-center study with 245 patients, DLI were classified by their local appearance using a modification of a score suggested by the Sharp Memorial group. The driveline exit site was inspected routinely every 6 months.

RESULTS

Severe DLI were detected in 34 patients (15%) after 6 months and in 24 patients (22%) after 24 months. The proportion of patients with DLI increased significantly during the follow-up (p = 0.0096). The most common bacteria in local smears were Corynebacterium, coagulase-negative Staphylococcus, and Staphylococcus aureus. Fifty-nine patients were hospitalized more than once for DLI. In these patients, S. aureus was the most common bacterium. It was also the most common bacterium in blood cultures. Higher BMI, no partnership, and a HeartMate 3 device were identified as risk factors for DLI in a multivariable cause-specific Cox regression.

CONCLUSION

This study is a standardized analysis of DLI in a large cohort with centrifugal-flow LVADs.

Evolution of Mechanical Circulatory Support for advanced heart failure

This comprehensive review highlights the significant advancements in Left Ventricular Assist Device (LVAD) therapy, emphasizing its evolution from the early pulsatile flow systems to the cutting-edge continuous-flow devices, particularly the HeartMate 3 (HM3) LVAD. These advancements have notably improved survival rates, reduced complications, and enhanced the quality of life (QoL) for patients with advanced heart failure. The dual role of LVADs, as a bridge-to-transplantation and destination therapy is discussed, highlighting the changing trends and policies in their application. The marked reduction in hemocompatibility-related adverse events (HRAE) with the HM3 LVAD, compared to previous models signifies ongoing progress in the field. Challenges such as managing major infections are discussed, including innovative solutions like energy transfer systems aimed at eliminating external drivelines. It explores various LVAD-associated complications, including HRAE, infections, hemodynamic-related adverse events, and cardiac arrhythmias, and underscores emerging strategies for predicting post-implantation outcomes, fostering a more individualized patient care approach. Tools such as the HM3 risk score are introduced for predicting survival based on pre-implant factors, along with advanced imaging techniques for improved complication prediction. Additionally, the review highlights potential new technologies and therapies in LVAD management, such as hemodynamic ramp tests for optimal speed adjustment and advanced remote monitoring systems. The goal is to automate LVAD speed adjustments based on real-time hemodynamic measurements, indicating a shift towards more effective, patient-centered therapy. The review concludes optimistically that ongoing research and potential future innovations hold the promise of revolutionizing heart failure management, paving the way for more effective and personalized treatment modalities.

Efficacy and Complication Profiles of Left Ventricular Assist Devices in Adult Heart Failure Management: A Systematic Review and Meta-Analysis

Left ventricular assist devices (LVADs) have marked a milestone in the evolution of treatment for patients with end-stage heart failure. Their popularity and use are steadily rising. This systematic review and meta-analysis aimed to evaluate the effectiveness of LVADs in improving the survival rate of patients with end-stage heart failure and to identify the complications or adverse events associated with LVAD use. Articles for this systematic review and meta-analysis were sourced from PubMed, Google Scholar, and the Cochrane Library databases. Only studies that met the predefined PICOS eligibility criteria were analyzed. LVADs significantly improved the 6, 12, 18, and 24-month survival rates in patients with end-stage heart failure compared to no LVAD or other therapies: OR 1.87 (95%CI [1.27-2.76]), OR 2.29 (95%CI [1.61-3.26]), OR 2.07 (95%CI [0.61-6.61]), and OR 1.73 (95%CI [0.88-3.41]) for 6, 12, 18, and 24 months, respectively. The incidence of adverse events was significantly higher in the LVAD group than in the non-LVAD treatments: bleeding OR 12.53 (95%CI [2.60-60.41]), infections OR 4.15 (95%CI [1.19-14.45]), stroke OR 2.58 (95%CI [1.38-4.82]), and arrhythmia OR 2.81 (95%CI [1.64-4.80]). Overall, complications were higher in the LVAD group compared to those without LVAD treatment. Hospital readmissions due to adverse events were significantly more frequent in the LVAD group, OR 2.98 (95%CI [1.38-6.43]). Despite the elevated risk of adverse events associated with LVADs, these devices have demonstrated a notable enhancement in the survival outcomes for patients with end-stage heart failure.

Clinical Outcomes of Left Ventricular Assist Device Pump Infection

Few studies have focused on the clinical outcomes and risk factors of left ventricular assist device (LVAD) pump infection, and no standard treatment for LVAD pump infection has been established. Therefore, we used a therapeutic flowchart to manage LVAD pump infections. We retrospectively evaluated 220 patients who underwent continuous-flow LVAD implantation between January 2005 and March 2021 at Osaka University, Japan. First, we performed wound debridement, negative-pressure wound therapy, antibiotic treatment, and omental flap transposition. Subsequently, we administered conservative treatment, scheduled implantable LVAD exchange, or emergent removal of the implantable LVAD and exchange for extracorporeal LVAD or percutaneous LVAD (IMPELLA). Pump infections occurred in 32 patients. The survival rates of patients with pump infections during LVAD support were 93%, 74%, and 61% at 180 days, 1 year, and 2 years after LVAD pump infection, respectively. Fifteen patients underwent successful heart transplantation. Bridge-to-bridge surgery, preoperative use of venoarterial extracorporeal membrane oxygenation or percutaneous LVAD, high lactate dehydrogenase levels, and driveline infection were significantly associated with pump infection. Our study reveals that poor preoperative condition and driveline infection were significant risk factors for LVAD pump infection.

Transdermal wires for improved integration in vivo

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.

Dynamics of bacterial pathogens at the driveline exit site in patients with ventricular assist devices: A prospective, observational, single-center cohort study

BACKGROUND

Driveline infections (DLIs) at the exit site are frequent in patients with left ventricular assist devices (LVADs). The dynamics from colonization to infection are yet to be investigated. We combined systematic swabbing at the driveline exit site and genomic analyses to study the dynamics of bacterial pathogens and get insights into DLIs pathogenesis.

METHODS

A prospective, observational, single-center cohort study at the University Hospital of Bern, Switzerland was performed. Patients with LVAD were systematically swabbed at the driveline exit site between June 2019 and December 2021, irrespective of signs and symptoms of DLI. Bacterial isolates were identified and a subset was whole-genome sequenced.

RESULTS

Fifty-three patients were screened, of which 45 (84.9%) were included in the final population. Bacterial colonization at the driveline exit site without manifestation of DLI was frequent and observed in 17 patients (37.8%). Twenty-two patients (48.9%) developed at least one DLI episode over the study period. Incidence of DLIs reached 2.3 cases per 1000 LVAD days. The majority of the organisms cultivated from exit sites were Staphylococcus species. Genome analysis revealed that bacteria persisted at the driveline exit site over time. In four patients, transition from colonization to clinical DLI was observed.

CONCLUSIONS

Our study is the first to address bacterial colonization in the LVAD-DLI setting. We observed that bacterial colonization at the driveline exit site was a frequent phenomenon, and in a few cases, it preceded clinically relevant infections. We also provided acquisition of hospital-acquired multidrug-resistant bacteria and the transmission of pathogens between patients.

Treatment of fungal infection on left ventricle assist device driveline exit site: a case report and systematic review

OBJECTIVE

The use of ventricular assist devices (VAD) is increasing; however, diagnosis and management of device complications, such as the driveline exit site (DES) being the portal of entry for fungal infection, is not well known.

METHOD

A systematic review involving searching PubMed (2005 to July 2020) was conducted. The case of a 43-year-old female patient who had a left VAD (LVAD) (HeartMate 3, Abbott, US) is also reported.

RESULTS

The patient was successfully treated with ketoconazole cream and oral fluconazole for likely superficial DES fungal infections. We included 36 studies that met our inclusion criteria; however, only one was included in our review. In the literature, five cases of DES fungal infection were reported, with Candida being the only fungal pathogen.

CONCLUSION

LVAD fungal infections are uncommon but can be responsible for high mortality rates, require a prolonged period of treatment, and can present a huge problem when surgical alternatives are not available. However, Candida species are most common. Fungal infections can only produce clear discharge, and so the classic definition of driveline infection based on purulent secretion can vary. Negative skin culture does not exclude the diagnosis of infection of the DES, and so empirical diagnosis may only be clinically based.

Left Ventricular Assist Device: Review of Antimicrobial Prophylaxis Strategies and Incidence of Infections at a Tertiary Care Center 12-Year Experience

Background

Left ventricular assist devices (LVAD) have an associated infection rate of 13%-80% postimplant. An optimal strategy for surgical infection prophylaxis (SIP) at the time of implantation has not been well defined. We aimed to evaluate the different LVAD implantation antibiotic prophylaxis regimens as well as the incidence of LVAD infection at our institution.

Methods

We performed a single-center, retrospective study of patients who underwent LVAD implantation between February 2007 and June 2019. The primary outcome was the incidence of LVAD infection (LVADI), within 3 months and 1 year of placement, between patients who received expanded or narrow-spectrum regimens for SIP. We assessed outcomes using Kaplan-Meier, time-to-first event. We used a noninferiority analysis, which was established if the narrow-spectrum event rate was no more than 5% greater than the expanded-spectrum event rate.

Results

We included 399 patients, 305 (76.4%) patients received narrow-spectrum SIP, whereas the remaining 94 (23.6%) patients received the expanded-spectrum regimen. Statistical noninferiority of the narrow spectrum to the multiple drug regimen was demonstrated at both time points, and statistical superiority of the narrow-spectrum group across 12-month follow up was further evident (P = .037).

Conclusions

We report evidence supporting noninferiority, or even superiority, of the narrow-spectrum over expanded-spectrum antimicrobial prophylaxis strategy with respect to LVADI. These findings support data-driven antimicrobial prophylaxis strategies.

Infections in Patients With Left Ventricular Assist Devices: Current State and Future Perspectives

Mechanical circulatory support is increasingly being used as bridge-to-transplant and destination therapy in patients with advanced heart failure. Technologic improvements have led to increased patient survival and quality of life, but infection remains one of the leading adverse events following ventricular assist device (VAD) implantation. Infections can be classified as VAD-specific, VAD-related, and non-VAD infections. Risk of VAD-specific infections, such as driveline, pump pocket, and pump infections, remains for the duration of implantation. While adverse events are typically most common early (within 90 days of implantation), device-specific infection (primarily driveline) is a notable exception. No diminishment over time is seen, with event rates of 0.16 events per patient-year in both the early and late periods postimplantation. Management of VAD-specific infections requires aggressive treatment and chronic suppressive antimicrobial therapy is indicated when there is concern for seeding of the device. While surgical intervention/hardware removal is often necessary in prosthesis-related infections, this is not so easily accomplished with VADs. This review outlines the current state of infections in patients supported with VAD therapy and discusses future directions, including possibilities with fully implantable devices and novel approaches to treatment.

Daptomycin Pharmacokinetics in Blood and Wound Fluid in Critical Ill Patients with Left Ventricle Assist Devices

Daptomycin is a cyclic lipopeptide antibiotic with bactericidal effects against multidrug-resistant Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecalis (VRE). For critically ill patients, especially in the presence of implants, daptomycin is an important therapeutic option. Left ventricle assist devices (LVADs) can be utilized for intensive care patients with end-stage heart failure as a bridge to transplant. We conducted a single-center prospective trial with critically ill adults with LVAD who received prophylactic anti-infective therapy with daptomycin. Our study aimed to evaluate the pharmacokinetics of daptomycin in the blood serum and wound fluids after LVAD implantation. Daptomycin concentration were assessed over three days using high-performance liquid chromatography (HPLC). We detected a high correlation between blood serum and wound fluid daptomycin concentration at 12 h (IC95%: 0.64 to 0.95; r = 0.86; p < 0.001) and 24 h (IC95%: -0.38 to 0.92; r = 0.76; p < 0.001) after antibiotic administration. Our pilot clinical study provides new insights into the pharmacokinetics of daptomycin from the blood into wound fluids of critically ill patients with LVADs.

Long-term assist device patients admitted to ICU: Tips and pitfalls

Left ventricular assist device (LVAD) therapy is well-established in the treatment of end-stage cardiac failure. Indications are bridge to transplant (BTT), bridge to candidacy (BTC), bridge to recovery (BTR), and destination therapy (DT). The durability and adverse event (AE) rate of LVADs have improved over the years. However, due to donor shortage, the duration of support in the BTT population has increased tremendously; similarly, DT patients are on the device for a long time. Consequently, the number of readmissions of long-term LVAD patients has increased. In cases of severe AEs, intensive care unit (ICU) treatment can be necessary. Infectious complications are the most common AE. Furthermore, embolic or hemorrhagic strokes can occur due to foreign surfaces, acquired von Willebrand syndrome, and anticoagulation treatment. Another consequence of the coagulative status, in combination with the continuous flow, are gastrointestinal bleeding events. Moreover, in most patients, an isolated LVAD is implanted, and this involves the risk of late right heart failure. Adjustment of pump speed and optimization of the volume status can help solve this issue. Malignant arrhythmias, pre-existing or de novo after LVAD implantation, can be a life-threatening AE. Antiarrhythmic medical therapy or ablation are potential treatment options. As for specific LVADs, the Medtronic HeartWare™ ventricular assist device (HVAD) is not manufactured and distributed currently; however, 4000 patients are still on the device. Pump thrombosis can occur, wherein thrombolytic therapy is the first-line treatment option. Additionally, the HVAD can fail to restart after controller exchange due to technical issues, and precautions must be taken. The Momentum 3 trial showed superior survival without pump exchange or disabling stroke in patients treated with the HeartMate 3^Ⓡ (HM3; Abbott, Abbott Park, IL, USA) device in comparison to the HeartMate II (HMII). However, in a few cases, a twisted graft or bio debris formation between the outflow graft and bend relief could be observed, causing outflow graft obstruction. Patients on LVADs are still heart failure patients, in many cases with comorbidities. Therefore, many situations can occur requiring ICU treatment. Ethical aspects should always be the focus when taking care of these patients.

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

BACKGROUND

Driveline infection (DLI) following left ventricular assist device (LVAD) implantation remains an unresolved problem. Negative pressure wound therapy (NPWT) promotes wound healing by applying negative pressure on the surface of the wound. Recently, the prophylactic application of NPWT to closed surgical incisions has decreased surgical site infections in various postsurgical settings. Therefore, we evaluated the efficacy and safety of prophylactic NPWT for preventing DLI in patients with LVAD implantation.

METHODS

Prophylactic NPWT was provided to 50 patients who received continuous-flow LVADs as bridge-to-transplant therapy at our institution between May 2018 and October 2020 (NPWT group). The negative pressure dressing was applied immediately after surgery and retained on the driveline exit site for 7 days with a continuous application of -125 mm Hg negative pressure. The primary outcome was DLI within 1 year of LVAD implantation. We compared the rate of DLI incidence in the NPWT group with that in the historical control cohort (50 patients) treated with the standard dressing (SD) who received LVAD implantation between July 2015 and April 2018 (SD group).

RESULTS

No severe complications were associated with the NPWT. During the follow-up period, DLI was diagnosed in 16 participants (32%) in the NPWT group and 21 participants (42%) in the SD group. The rates of DLI incidence and freedom from DLI did not differ between groups (p = 0.30 and p = 0.63).

CONCLUSIONS

Prophylactic NPWT at the driveline exit site was safe following LVAD implantation. However, it did not significantly reduce the risk of DLI.

HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support

The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.

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

BACKGROUND

We evaluated the impact of a standardized driveline care strategy, including a subfascial-tunneling method and dressing protocol, on the incidence of driveline infection (DLI).

METHODS

DLI data from all HeartMate II (HMII) and HeartMate 3 (HM3) patients (including exchange devices) were retrospectively collected between 2013 and 2021. The driveline subfascial-tunneling method was altered in three steps (A: right direct; B: left triple, C: right triple), and the shower protocol was changed in two steps (A: with/without cover, B: with cover). Disinfection was individually tailored after changing the shower protocol. Complications associated with morbidity and mortality were evaluated for each modification.

RESULTS

During the study period, 80 devices were implanted (HMII, n = 54; HM3, n = 26). The 8-year incidence of DLI was 15% (n = 8) in HMII patients and 0% in HM3 patients (p = 0.039). DLI was not associated with hospital mortality. The modified dressing protocol and tunneling method was associated with a significantly better DLI incidence rate in comparison to the previous one: Protocol-A (n = 17), Protocol-B (n = 63), 35% vs 3% (p = 0.0009), Method-A (n = 13), Method-B (n = 42), Method-C (n = 25), 46% vs 5% vs 0% (p = 0.0001). The rete of freedom form DLI at 1, 2, and 3 years had also significant difference between groups: Protocol-A and Protocol-B, 80%, 54%, 54% vs 96%, 96%, 96%, respectively (p < 0.0001), Method-A, Method-B and Method-C, 76%, 44%, 44%, vs 94%, 94%, 94% vs 100%, 100%, respectively (p < 0.0001).

CONCLUSIONS

A standardized triple driveline tunneling strategy and waterproof dressing protocol reduced driveline infection in HM3 patients to 0%.

Molecular Imaging of Valvular Diseases and Cardiac Device Infection

The use of positron emission tomography imaging with 18F-fluorodeoxyglucose in the diagnostic workup of patients with suspected prosthetic valve endocarditis and cardiac device infection (implantable electronic device and left ventricular assist device) is gaining momentum in clinical practice. However, in the absence of prospective randomized trials, guideline recommendations about 18F-fluorodeoxyglucose positron emission tomography in this setting are currently largely based on expert opinion. Measurement of aortic valve microcalcification occurring as a healing response to valvular inflammation using 18F-sodium fluoride positron emission tomography represents another promising clinical approach, which is associated with both the risk of native valve stenosis progression and bioprosthetic valve degeneration in research trials. In this review, we consider the role of molecular imaging in cardiac valvular diseases, including aortic stenosis and valvular endocarditis, as well as cardiac device infections.

Delayed versus primary sternal closure for left ventricular assist device implantation: Impact on mechanical circulatory support infections

BACKGROUND

Delayed sternal closure may be required after left ventricular assist device (LVAD) implantation due to coagulopathy or hemodynamic instability. There is conflicting data regarding infection risk.

METHODS

We performed a single-center, retrospective analysis of patients who received their first LVAD between May 2012 and January 2021. Patients were divided into delayed sternal closure (DSC) and primary sternal closure (PSC) groups. We used chi-squared or Fisher Exact tests, as appropriate, to compare the incidence of postoperative LVAD-related infections (mediastinal/sternal wound) and LVAD-specific infections (driveline and pump pocket) after definitive chest closure between these two groups.

RESULTS

A total of 327 patients met eligibility criteria, including 127 (39%) patients that underwent DSC and 200 (61%) patients that had a PSC. Demographic and clinical characteristics were similar except for an overrepresentation of men (87% vs. 75%, p = .016), Interagency Registry of Mechanically Assisted Circulatory Support class I-II patients (89% vs 66%, p < .001), patients with a previous sternotomy (43% vs 13%, p < .001), and patients with chronic kidney disease (55% vs 43%, p = .030) in the DSC group. The median DSC time was 24 (IQR: 24-48) hours. The incidence of LVAD-related mediastinal/sternal wound infection was similar between the DSC and PSC groups (4.7% vs 3.0%, p = .419). There was no difference between DSC and PSC groups in the incidence of driveline infection (6.3% vs 9%, p = .411) and pump pocket infection (1.6% vs 1.5%, p =.901), respectively.

CONCLUSIONS

DSC does not seem to increase the incidence of LVAD-related or LVAD-specific infection rates in heart failure patients undergoing device implantation surgery.