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Charles J, Girgis M, Nezami N, Massis K, Davis C, Hoots G, Shaikh J. Interventional Radiological Treatment of Orthotopic Heart Transplant Complications. Tech Vasc Interv Radiol 2023; 26:100928. [PMID: 38123286 DOI: 10.1016/j.tvir.2023.100928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Orthotopic heart transplantation is a life-saving procedure that has substantially improved the lives of countless patients since its inception. However, there are several procedure-related complications that require prompt management. Interventional radiology, with its ever expanding toolkit, is a cornerstone of the multidisciplinary team following post-cardiac transplant patients. Percutaneous, endovascular therapy provides minimally invasive, safe, and effective treatments for immediate and delayed cardiac transplant complications and this paper serves to highlight the various management options interventional radiology can provide for orthotopic heart transplantation complications.
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Affiliation(s)
| | | | - Nariman Nezami
- Department of DIagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | - Kamal Massis
- University of South Florida Medical School, Tampa, FL
| | - Cliff Davis
- Department of Vascular and Interventional Radiology, University of South Florida , Tampa, FL
| | - Glenn Hoots
- Department of Vascular and Interventional Radiology, University of South Florida , Tampa, FL
| | - Jamil Shaikh
- Department of Vascular and Interventional Radiology, University of South Florida , Tampa, FL.
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2
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Immohr MB, Böttger C, Aubin H, Westenfeld R, Oehler D, Bruno RR, Dalyanoglu H, Tudorache I, Akhyari P, Lichtenberg A, Boeken U. IgM-enriched immunoglobulin as adjuvant therapy for heart transplant after infection of left ventricular assist devices. ESC Heart Fail 2022; 9:3630-3635. [PMID: 35854478 DOI: 10.1002/ehf2.14074] [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: 04/18/2022] [Revised: 06/07/2022] [Accepted: 06/27/2022] [Indexed: 11/07/2022] Open
Abstract
Patients undergoing heart transplantation (HTx) with active infection of left ventricular assist devices (LVAD) are at high risk for postoperative infections. Between 2021 and 2022, five (P1-P5) of a total of n = 44 patients underwent HTx in our department while suffering from LVAD infection. Postoperatively, patients received adjuvant IgM-enriched human intravenous immunoglobulin (IGM-IVIG), consisting of 76% IgG, 12% IgM, and 12% IgA as a novel approach to prevent infective complications. While in P1, P2, and P4, LVAD driveline infection was known before HTx; in P3 and P5, abscess of device pocket was found incidentally during HTx. After a single dose of IGM-IVIG, all patients showed adequate rise in serum immunoglobulins. In the postoperative course, no patient developed infective complications. All patients were successfully discharged and in good condition at the last follow-up. Therefore, IGM-IVIG seems to be an effective adjuvant treatment for patients undergoing HTx with LVAD infections.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Charlotte Böttger
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Oehler
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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3
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Iwata N, Shibata SC, Yoshioka D, Uchiyama A, Toda K, Sawa Y, Fujino Y. Impact of Ventricular Assist Device-Specific Infections on Post-Heart Transplant Infections: A Retrospective Single-Center Study. Transplant Proc 2021; 53:3030-3035. [PMID: 34732298 DOI: 10.1016/j.transproceed.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/31/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with a ventricular assist device (VAD) who are awaiting heart transplant (HTx) are susceptible to infections. Such infections, especially at the site of the VAD, may increase the risk of severe post-transplant infections and mortality. Information on the characteristics of VAD-specific infections and outcomes in HTx recipients after prolonged periods of LVAD therapy is scarce. PURPOSE We aimed to assess the impact of active VAD-specific infections on the incidence of early post-transplant infections and patient survival. METHODS We conducted a retrospective review of adult HTx cases at our center between April 2011 and October 2020. Informed consent was waived due to study design. A total of 86 patients were included in this study, among whom 94.2% (n = 81) were bridged with a VAD, and the median VAD support period was 1089 days. RESULTS Patients with active VAD-specific infections were significantly more likely to develop severe acute mediastinitis [odds ratio (OR) 14.8, 95% confidence interval (CI) 4.83-45.4, P < .01]. Active VAD infections were significantly related to increased length of intensive care unit stay (22.1 days vs 13.0 days, P = .016) and longer mechanical ventilation periods (324.7 hours vs 113.2 hours, P = .03). The 30-day survival rates for patients with and without post-transplant infections were 100% and 97.1%, respectively. CONCLUSION Compared to other risk factors, the presence of active VAD-specific infections increases the risk of early post-heart transplant infections and morbidity, without affecting mortality.
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Affiliation(s)
- Naomi Iwata
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Sho C Shibata
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akihiko Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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4
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Lambadaris M, Vishram-Nielsen JKK, Amadio JM, Husain S, Rao V, Billia F, Alba AC. Association between continuous-flow left ventricular assist device infections requiring long-term antibiotic use and post-heart transplant morbidity and mortality. J Card Surg 2021; 37:96-104. [PMID: 34651943 DOI: 10.1111/jocs.16073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM OF STUDY There exists controversy regarding the impact of infection in patients with a left ventricular assist device (LVAD) on post-heart transplant outcomes. This study evaluated the association between infections during LVAD support and the risk of early and late post-heart transplant infection, rejection, and mortality in transplant recipients bridged with an LVAD. METHODS This is a single-center retrospective observational cohort study of consecutive adults supported with a continuous flow LVAD undergoing heart transplant between 2006 and 2019 at the Toronto General Hospital. The grade of LVAD infection was classified as per International Society of Heart and Lung Transplantation guidelines. Patients were divided into three groups: (1) patients with LVAD-specific infection confirmed with positive cultures requiring long-term antibiotic use until the time of transplant; (2) patients with any type of infection in whom antibiotics were stopped at least 1 month before transplant; (3) patients without any infections between LVAD implant and transplant. Logistic regression and Cox proportional hazard models were used to evaluate early- and late-post transplant outcomes, respectively. RESULTS We included 75 LVAD recipients: 16 (21%) patients had a chronic LVAD-related infection on suppressive antibiotics, 30 (40%) had a resolved infection, and 29 (39%) had no infections. During a median post-transplant follow-up time of 4 (2 to 7) years, 65 (87%) patients developed infections, 43 (64%) rejections, and 17 (23%) deaths. Both short- and long-term risks of infection, rejection, and mortality did not differ significantly among the groups. CONCLUSION LVAD patients with infections did not have a significantly higher risk of infection, rejection, or mortality at any time point after transplant.
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Affiliation(s)
- Maria Lambadaris
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Julie K K Vishram-Nielsen
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Jennifer M Amadio
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Vivek Rao
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Filio Billia
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Ted Rogers Center for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Ana C Alba
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Ted Rogers Center for Heart Research, University Health Network, Toronto, Ontario, Canada
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5
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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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Impact of Induction Immunosuppression on Post-Transplant Outcomes of Patients Bridged with Contemporary Left Ventricular Assist Devices. ASAIO J 2020; 66:261-267. [PMID: 32101996 DOI: 10.1097/mat.0000000000001119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
For patients bridged to transplant (BTT) with left ventricular assist devices (LVAD), data regarding the use of induction immunosuppressive therapy remain limited. The objectives of the current study were to describe the current trends and clinical consequences of IT in patients BTT with LVAD. The United Network of Organ Sharing database was queried to identify adult, single-organ heart transplant recipients who were BTT with LVAD between 2008 and 2018. Propensity score matching was then used to balance clinical covariates between those patient who did and did not receive IT. The primary outcomes of interest were graft survival, hospitalization for rejection and infection, and freedom from transplant coronary artery disease (TCAD). In the overall cohort, 49.1% (n = 3,978) received IT, with basiliximab being the most commonly used agent followed by antithymocyte globulin. After propensity score matching, 4,388 patients (2,194 without induction and 2,194 with induction) were identified. Between those who did and did not receive IT, there was no significant difference in graft survival, freedom from hospitalization for rejection, and freedom from hospitalization for infection. Patients who received IT experienced increased freedom from TCAD (p = 0.004) with unadjusted hazard ratio of 0.81 (95% Cardiac Index: 0.70-0.93). For freedom from TCAD, antithymocyte globulin was associated with better outcomes than basiliximab (80.2% vs. 73.1% at 5 years, log rank p value = 0.004). In a sensitivity analysis, there was no significant increase in hospitalization for infection in those patients with an infected LVAD before transplant. Use of induction therapy in patients BTT with LVAD appears to be safe and feasible, without a significant increase in the risk of infection or rejection, even in those patients with pretransplant device-related infections. IT, particularly antithymocyte globulin, was associated with increased time to development of TCAD. Routine use of IT in patients BTT with LVAD may be considered, and further randomized control trials are warranted to further support these data.
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Moayedi Y, Multani A, Bunce PE, Henricksen E, Lee R, Yang W, Gomez CA, Garvert DW, Tremblay-Gravel M, Duclos S, Hiesinger W, Ross HJ, Khush KK, Montoya JG, Teuteberg JJ. Outcomes of patients with infection related to a ventricular assist device after heart transplantation. Clin Transplant 2019; 33:e13692. [PMID: 31403741 DOI: 10.1111/ctr.13692] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/06/2019] [Accepted: 08/09/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite significant advances in durable mechanical support survival, infectious complications remain the most common adverse event after ventricular assist device (VAD) implantation and the leading cause of early death after transplantation. In this study, we aim to describe our local infectious epidemiology and review short-term survival and infectious incidence rates in the post-transplantation period and assess risk factors for infectious episodes after transplantation. METHODS Retrospective single-center study of all consecutive adult heart transplant patients from 2008 to 2017. Survival data were estimated and summarized using the Kaplan-Meier method. We quantified and evaluated the difference in the incidence rate between patients with and without infection using a Fine-Gray model. The outcome of interest is the time to first infection diagnosis with post-transplant death as the competing event. RESULTS Among 278 heart transplant patients, 74 (26.5%) underwent LVAD implantation. Twenty-one patients (28.3%) developed an infection while supported by an LVAD. When compared to patients supported by an LVAD without a preceding infection, BMI was significantly greater (31.2 vs 27.8 kg/m2 , P = .03). Median follow-up post-transplantation was 3.01 years. Significant risk factors for the competing risk regression for infection after heart transplantation include LVAD infection (HR 1.94, [95% CI] 1.11-3.39, P = .020) and recipient COPD (HR 2.14, [95% CI] 1.39-3.32, P = .001) when adjusted for recipient age, gender, hypertension, diabetes mellitus, and body mass index. CONCLUSIONS Patients with LVAD-related infection had a significantly increased risk of infectious complications after heart transplantation. Further research on the avoidance of induction agents and reduced maintenance immunosuppression in this patient population is warranted.
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Affiliation(s)
- Yasbanoo Moayedi
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA.,Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Ashrit Multani
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Paul E Bunce
- Department of Medicine, Division of Infectious Disease, University Health Network, Toronto, ON, Canada
| | - Erik Henricksen
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA
| | - Roy Lee
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wenjia Yang
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA
| | - Carlos A Gomez
- Department of Medicine, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Donn W Garvert
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Maxime Tremblay-Gravel
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA
| | - Sebastien Duclos
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA
| | - William Hiesinger
- Department of Cardiovascular Surgery, Stanford University, Stanford, CA, USA
| | - Heather J Ross
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Kiran K Khush
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA
| | - Jose G Montoya
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Palo Alto Medical Foundation, Toxoplasma Serology Laboratory (PAMF-TSL), National Reference Center for the Study and Diagnosis of Toxoplasmosis, Palo Alto, CA, USA
| | - Jeffrey J Teuteberg
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA
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VAD infection during bridge-to-transplant, unique aspects of treatment and prevention. Curr Opin Organ Transplant 2019; 23:400-406. [PMID: 29979263 DOI: 10.1097/mot.0000000000000548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW VAD infections remain a frequent complication of VAD care and can markedly affect patient management before and after transplantation. This review highlights the standard-of-care approaches offered by recent guidelines as well as published data that may improve the care for patients with these challenging and often persistent infections. RECENT FINDINGS Prevention and management of VAD infections has become more standardized with updated consensus guidelines published in 2017. Unfortunately, advanced devices have not markedly affected the incidence of VAD infection. Efforts to improve, yet streamline, the prevention of VAD-specific infections are ongoing. However, the data provided in the best of recent publications are rarely effectively comparative. Granular data on management strategies are limited to a few studies. Nevertheless, several publications provide more detailed posttransplant outcomes for patients with pretransplant VAD infections and demonstrate overall excellent posttransplant survival. SUMMARY Prevention and management of VAD-specific and VAD-related infections are the ongoing work of all VAD programs. Consensus guidelines are a marker of progress for this field. Despite very good posttransplant outcomes for these patients, more granular data are required to understand how such patients arrive successfully to transplantation and how their posttransplant course is affected.
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Koval CE, Stosor V. Ventricular assist device-related infections and solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13552. [PMID: 30924952 DOI: 10.1111/ctr.13552] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 01/06/2023]
Abstract
The Infectious Diseases Community of Practice of the American Society of Transplantation has published evidenced-based guidelines on the prevention and management of infectious complications in SOT recipients since 2004. This updated guideline reviews the epidemiology of ventricular assist device (VAD) infections and provides recommendations for the management and prevention of these infections. Almost one half of those awaiting heart transplantation are supported with VADs. Despite advances in device technologies, VAD infections commonly complicate mechanical circulatory support and remain typified by common components and anatomic locations. These infections have important implications for transplant candidates, most notably increased wait-list mortality. Strategic management of these infections is crucial for successful transplantation. Coincidentally, explantation of all VAD components at the time of transplantation is often the definitive cure for the device-associated infection. Highlighted in this updated guideline is the reported success of transplantation in patients with a variety of pre-existing VAD infections and guidance on post-transplant management strategies.
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Affiliation(s)
- Christine E Koval
- Department of Infectious Diseases, Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.,Transplant Infectious Diseases, Transplant Center, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Valentina Stosor
- Medicine and Surgery, Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Pons S, Sonneville R, Bouadma L, Styfalova L, Ruckly S, Neuville M, Radjou A, Lebut J, Dilly MP, Mourvillier B, Dorent R, Nataf P, Wolff M, Timsit JF. Infectious complications following heart transplantation in the era of high-priority allocation and extracorporeal membrane oxygenation. Ann Intensive Care 2019; 9:17. [PMID: 30684052 PMCID: PMC6347647 DOI: 10.1186/s13613-019-0490-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 01/12/2019] [Indexed: 01/09/2023] Open
Abstract
Background Infectious complications are a major cause of morbidity and mortality after heart transplantation (HT). However, the epidemiology and outcomes of these infections in the recent population of adult heart transplant recipients have not been investigated. Methods We conducted a single-center retrospective study on infectious complications occurring within 180 days following HT on consecutive heart transplant recipients, from January 2011 to June 2015 at Bichat University Hospital in Paris, France. Risk factors for non-viral infections occurring within 8, 30 and 180 days after HT were investigated using competing risk analysis. Results Overall, 113 patients were included. Fifty-eight (51%) HTs were high-priority allocations. Twenty-eight (25%) patients had an extracorporeal membrane oxygenation (ECMO) support at the time of transplantation. Ninety-two (81%) patients developed at least one infection within 180 days after HT. Bacterial and fungal infections (n = 181 episodes) occurred in 80 (71%) patients. The most common bacterial and fungal infections were pneumonia (n = 95/181 episodes, 52%), followed by skin and soft tissue infections (n = 26/181, 14%). Multi-drug-resistant bacteria were responsible for infections in 21 (19%) patients. Viral infections were diagnosed in 44 (34%) patients, mostly Cytomegalovirus infection (n = 39, 34%). In multivariate subdistribution hazard model, prior cardiac surgery (subdistribution hazard ratio sHR = 2.7 [95% CI 1.5–4.6] p < 0.01) and epinephrine or norepinephrine at the time of HT (sHR = 2.3 [95% CI 1.1–5.2] p = 0.04) were significantly associated with non-viral infections within 8 days after HT. Prior cardiac surgery (sHR = 2.5 [95% CI 1.4–4.4] p < 0.01), recipient age over 60 years (sHR = 2.0 [95% CI 1.2–3.3] p < 0.01) and ECMO following HT (sHR = 1.7 [95% CI 1.0–2.8] p = 0.04) were significantly associated with non-viral infection within 30 days after HT, as well as within 180 days after HT. Conclusion This study confirmed the high rate of infections following HT. Recipient age, prior cardiac surgery and ECMO following HT were independent risk factors for early and late bacterial and fungal infections. Electronic supplementary material The online version of this article (10.1186/s13613-019-0490-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stéphanie Pons
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Romain Sonneville
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France. .,UMR 1148, LVTS, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France.
| | - Lila Bouadma
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases Prevention, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
| | | | | | - Mathilde Neuville
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Aguila Radjou
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Jordane Lebut
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Marie-Pierre Dilly
- Department of Anesthesiology, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Bruno Mourvillier
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases Prevention, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
| | - Richard Dorent
- Department of Cardiac Surgery, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Patrick Nataf
- Department of Cardiac Surgery, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Michel Wolff
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases Prevention, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
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11
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Lerman DT, Hamilton KW, Byrne D, Lee DF, Zeitler K, Claridge T, Gray J, Minamoto GY. The impact of infection among left ventricular assist device recipients on post-transplantation outcomes: A retrospective review. Transpl Infect Dis 2018; 20:e12995. [PMID: 30199584 DOI: 10.1111/tid.12995] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/11/2018] [Accepted: 08/21/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Left ventricular assist device (LVAD) infections are common, and the consequences of LVAD infections on orthotopic heart transplantation (OHT) outcomes are not well described. AIMS The aim of this study was to describe clinical characteristics and evaluate risk factors for developing LVAD infections, and examine outcomes of LVAD-specific infections (VSI) after OHT. METHODS We retrospectively investigated the records of 74 consecutive patients at two institutions who had undergone LVAD placement and subsequent OHT between January 2007 and December 2012. RESULTS Forty-six of 74 (62%) LVAD recipients who underwent OHT had pre-transplant infections, and 18 (24%) had LVAD-specific infection (VSI), of which 71% were caused by gram-negative organisms. Of pre-transplant non-LVAD infections, Clostridium difficile infection (CDI) was the most common (26%) followed by urinary tract infection (UTI, 16%) and pneumonia (PNA 15%). Univariate analysis comparing subjects with VSI to those without VSI showed a significant association with time spent outside the hospital prior to transplantation (median 231.8 days vs 142.2 days, P < 0.03) and total time between VAD placement and OHT (244.0 days and 150.5 days, P < 0.002). Logistic regression was performed and significant predictors for VAD-related infection were age and the presence of diabetes, with type of device as an effect modifier. Six months post-OHT survival was not significantly affected by the presence of VSI prior to transplant. There was a trend toward an association between the presence of any infection and post-transplant rejection (P < 0.09). There were 10 post-transplant deaths by 6 months. Of these deaths, 4/10 (40%) were cardiopulmonary and 6/10 (60%) were related to infections. CONCLUSIONS Advanced age and presence of diabetes were predictors of VSI, as well as type of VAD device, although device choice is likely affected by many clinical factors including age and comorbidities, as well as institution-specific preferences. VSI was not associated with a decrease in 6-month post-OHT survival. However, infections remain the major causes of death by 6 months post-transplant. Certain infections are associated with an increased risk of rejection, which merits further investigation.
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Affiliation(s)
- Dana T Lerman
- Departments of Medicine, Division of Infectious Diseases at Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Keith W Hamilton
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dana Byrne
- Cooper University Hospital, Camden, New Jersey
| | - Doreen F Lee
- Departments of Medicine, Division of Infectious Diseases at Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | | | - Tamara Claridge
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jaime Gray
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace Y Minamoto
- Departments of Medicine, Division of Infectious Diseases at Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Abe R, Shibata SC, Saito S, Tsukamoto Y, Toda K, Uchiyama A, Sakata Y, Sawa Y, Tomono K, Fujino Y. Factors Related to the Severity of Early Postoperative Infection After Heart Transplantation in Patients Surviving Prolonged Mechanical Support Periods: Experience at a Single University. J Cardiothorac Vasc Anesth 2018; 32:53-59. [DOI: 10.1053/j.jvca.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Indexed: 11/11/2022]
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13
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An ISHLT consensus document for prevention and management strategies for mechanical circulatory support infection. J Heart Lung Transplant 2017; 36:1137-1153. [DOI: 10.1016/j.healun.2017.06.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022] Open
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