Left Ventricular Assist Device Driveline Infections
Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.Cardiology clinics (Impact Factor: 1.03). 11/2011; 29(4):515-27. DOI: 10.1016/j.ccl.2011.08.004
This article reviews some important aspects of driveline infection in patients under left ventricular assist device (LVAD) support, including epidemiology, causes, diagnosis, and treatment options, both medical and surgical. Focus is placed on prevention along every aspect of the process of LVAD therapy, as the authors believe this is the most efficient measure to fight driveline infections. Once driveline infection is present, early recognition and adequate treatment, including surgical measures, play a central role management, and are key to achieving the goals of LVAD support.
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ABSTRACT: Infection is a major source of morbidity and mortality after ventricular assist device (VAD) implantation. The percutaneous driveline is the most common site of infection in these patients and often serves as a portal to deeper pump infections. There are no data defining the role of prophylactic antibiotics in preventing these infections. We compared all patients who underwent primary HeartMate II VAD implantation at two different institutions employing two different driveline infection prevention strategies between February 2007 and September 2011. While all patients received perioperative antibiotics, driveline maintenance strategies included sterile dressing changes with Hibiclens application without continued prophylactic antibiotics (Abx) (Mayo Clinic, n = 141, No Abx) and sterile dressing changes with continued prophylactic antibiotics (University of Michigan Hospital, n = 144, Abx). Although gender was similar between cohorts (Abx: 79% male vs. No Abx: 84% male, p = 0.25), median age at implant (Abx: 59 vs. No Abx: 64, p = 0.001) and destination therapy as indication for VAD (Abx: 22% vs. No Abx: 60%, p < 0.001) were significantly different. Follow-up was available in all late survivors (Abx: 140 patients, No Abx: 127 patients). Median duration of support was similar between groups (Abx: 12.3 months vs. No Abx: 11 months, p = 0.44). Total patient-years of device support were 172 years for 140 patients in the Abx cohort and 146 years for 127 patients in the No Abx cohort. Driveline drainage/infection was observed in 25 of 140 patients (18%) in the Abx group and 16 of 127 (13%) in the No Abx group (p = 0.15). Device exchange for major driveline infection was performed in seven patients in the Abx group and 0 patients in the No Abx group. Total driveline infection events per patient-years of support were 0.15 for the Abx group and 0.11 in the No Abx group (p = 0.43). There was no significant difference in the raw incidence of major driveline infections or driveline infections per patient-years of support in patients who were maintained on prophylactic antibiotics compared with those who were not. These data suggest that other factors may be more important than prophylactic antibiotics in preventing driveline infections.
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ABSTRACT: Although continuous-flow left ventricular assist device (LVAD) support has become standard therapy, the complexities of device and patient management remain a challenge. In particular, percutaneous site infections (PSI) are a serious complication during the post-implant course. We sought to study the incidence, risk factors, and clinical effect of PSI. Data were obtained from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Registry. All adult patients who received a primary intracorporeal continuous flow LVAD between June 2006 and September 2010 were included. Descriptive statistics, Kaplan-Meier depictions, and multivariable analysis in the parametric hazard domain were used for statistical analysis. A total of 239 PSIs were documented in 197 of 2,006 recipients (9.8%) of a continuous-flow LVAD. Mean follow-up was 8.1 months. Mean time to development of a PSI was 6.6 months. At 1 year after implant, nearly 19% of continuous-flow LVAD recipients developed a PSI. Multivariate analysis showed younger age (hazard ratio, 1.20; p < 0.0001) was the only factor predicting a PSI. Continuous-flow LVAD recipients who did not develop a PSI had improved survival (p = 0.004). Twenty-three patients died after development of a PSI. Sepsis was the most common cause of death (26.1%). PSIs occur in approximately 19% of continuous-flow LVAD recipients by 12 months after implant. Young age is the only predictor of PSI. Importantly, development of a PSI adversely affects survival. Efforts to enhance driveline integration and to develop future totally implantable systems are warranted.
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ABSTRACT: Infection is one of the major limitations to successful long-term support after ventricular assist device implantation. There are limited data specifically examining the incidence and predictors of driveline infections (DLI), with a changing treatment paradigm toward destination therapy (DT) and longer duration of support. Between January 2007 and 2011, 143 patients underwent HeartMate II (Thoratec, Pleasanton, CA) implantation, with 87 (61%) as DT. Driveline maintenance strategy included sterile dressing changes with chlorhexidine and saline application, without prophylactic oral antibiotics. DLI developed in 18 patients (12%) at a median of 182 days (range, 26 to 1,138 days) after implantation, among which 12 (66%) were from the DT cohort. Infections were superficial in 15 (82%) and deep in 3 (18%). Trauma was documented in 6 patients (33%). Seven patients (38%) needed readmission for DLI. Surgical debridement was needed in 3 (17%). All patients were managed successfully, without the need for device explantation or urgent cardiac transplantation. No patient required continuous antibiotic prophylaxis after the infection subsided. Risk factor analysis identified duration of support as the only independent predictor of infection (mean. 600 vs 390 days; p = 0.03). The odds of having a DLI rose by 4% for every month of support. Longer duration of support significantly increased the risk of DLI and hence increased the risk of DLI in patients with DT. DLI may be successfully managed with antibiotics and local wound care. Most of the infections were superficial, and progression to deep pocket or pump infection is rare in our experience.
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