Driveline Infections In Patients Research Articles

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 3years 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 3years 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.

Driveline Infection in Patients With Left Ventricular Assist Devices Implanted as Destination Therapy

Donor organ shortages cause increasing demand for mechanical circulatory support in patients with end-stage heart failure not only as a bridge to heart transplantation but mainly as a destination therapy. Improved results and increased applicability and durability of left ventricular assist devices (LVADs) have established this treatment option as an alternative to heart transplantation in selected patients. One of the most common complications after LVAD implantation is driveline infections (DLIs). This study aimed to expand the understanding of DLI epidemiology and potential changes in implantation techniques regarding optimizing DLI prevention and treatment among all patients undergoing LVAD (Medtronic's Heartware HVAD and HeartMate 3 Abbott LVAD system) implantation with at least 12 months of follow-up time between 2015 and 2022. There were 120 individuals with LVAD implantation, of whom 90 had 12 months of follow-up (85 men [94%], 5 women [6%]) with a median age of 58 years (50.25-63.75). The median body mass index was 27.12 kg/m2 (25.27-29.68). Of the 90 patients, 43 had ischemic heart failure (48%), 43 had dilated cardiomyopathy (48%), and the remaining 3 had other etiologies (3%), such as postinflammatory, and the remaining 1 had congenital heart defect (1%). Preoperative echocardiography revealed a mean left ventricle ejection fraction of 13.8% and a median left ventricle dimension of 7.55 cm (6.92-8.2). Imaging confirmed pulmonary hypertension in 61 patients (68%). Thirty-four of the 90 patients had diabetes (38%), and 16 were active smokers (18%). Median follow-up was 30 months (17.25-42), with the longest period being 82 months. More than half of the patients (n = 52; 57%) experienced a DLI. The median time to the first episode of DLI was 13 months (6-25). The most common pathogen revealed in wound swab culture was methicillin-sensitive Staphylococcus aureus (n = 23; 44%), Pseudomonas aeruginosa (n = 9; 17%), Proteus mirabilis (n = 4; 7%), and others. We observed that deeper driveline implantation below the left rectus muscle and just above the posterior rectus sheath resulted in fewer DLIs and longer free-from-DLI follow-up time. There was no statistically significant difference in DLI frequency between patients with or without diabetes mellitus. Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of destination therapy. DLI is the most common complication after LVAD implantation. Optimal surgical techniques and early implementation of targeted antibiotics are crucial. Significant challenges remain in optimizing DLI prevention and treatment.

Vitamin D deficiency and driveline infection in patients with a left ventricular assist device implant

Driveline infection is a frequent complication in recipients of durable left ventricular assist devices (LVAD), but its cause is largely unclear. Since vitamin D supplementation can reduce the risk of infections, we aimed at investigating the association of vitamin D deficiency with driveline infection. In 154 patients with continuous flow LVAD implants, we assessed 2-year risk of driveline infection according to vitamin D status (circulating 25-hydroxyvitamin D < 25 nmol/L or ⩾25 nmol/L). Of the study cohort, 34% (n = 53) had 25-hydroxyvitamin D concentrations <25 nmol/L. Kaplan-Meir estimates of 2-year freedom from driveline infection were in the vitamin D deficient and vitamin D non-deficient groups 49.7% and 74.2%, respectively (p = 0.017). Covariate-adjusted hazard ratio of driveline infection for the vitamin D deficient versus non-deficient group was 2.51 [95% CI: 1.11-5.69; p = 0.028). Circulating concentrations of endocrine regulators of calcium and phosphorus metabolism such as parathyroid hormone, 1,25-dihydroxyvitamin D, and fibroblast growth factor-23 were not significantly associated with the risk of driveline infection (p-values > 0.15). In total, our data indicate that in LVAD recipients deficient vitamin D status is a predictor of driveline infection, but future studies are needed to investigate whether these associations are causal.

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

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

Decreasing driveline infections in patients supported on ventricular assist devices: a care pathway approach

BackgroundDriveline infections (DLIs) are a common adverse event in patients on ventricular assist devices (VADs) with incidence ranging from 14% to 59%. DLIs have an impact on patients and the...

Pseudomonas aeruginosa LVAD Driveline Infection Acquired from the Bathroom at Home

<h3>Introduction</h3> Driveline infections in patients with a left ventricular assist device (LVAD) are feared due to significant morbidity and mortality. There might be great potential in preventive measures at home. <h3>Case Report</h3> A 54-year old patient showed a deep LVAD (HeartMate III) driveline infection by <i>Pseudomonas aeruginosa</i> shortly after his first shower at home. Despite 6 weeks of antibiotics (piperacillin/tazobactam, followed by ceftazidime and ciprofloxacin), surgical intervention was needed due to ongoing inflammation. To find the source of infection, culture swabs were taken from the patient's home bathroom (Figure 1). <i>P. aeruginosa</i> was found in the shower drain, wall-mounted shower jet (<b>B</b>) and non-slip shower mat (<b>D</b>). Typing by Multiple Locus Variable-Numbers Tandem Repeat Analysis to detect genetic congruence, revealed all bathroom strains to be highly similar to the exit site <i>P. aeruginosa</i>. <i>P. aeruginosa</i> thrives in moist environments. Contaminated drains and sinks are known to cause nosocomial infections. Our patient was probably infected at home by upward transmission as both the mat and shower drain tested <i>P. aeruginosa</i> positive<i>.</i> The wall mounted shower jet was positive, but not used. Airborne transmission was not investigated. Preventing driveline infections is important to reduce hospital re-admissions, repeated surgery and costs. We suggest instructions to prevent <i>Pseudomonas</i> infection (Table 1) and increase awareness on infection risks at home. These measures might also be protective for other water-borne pathogens. <h3>Summary</h3> Consider the patient's home bathroom as potential source of <i>P. aeruginosa</i> LVAD driveline infections.

Successful Cold Atmospheric Plasma Therapy of Driveline Infections in Patients with Left Ventricular Assist Devices

<h3>Purpose</h3> Driveline infections are still the Achilles heel of continuous flow left ventricular assist devices (cfLVAD) for morbidity and mortality in cfLVAD patients. Over the last years, cold atmospheric plasma (CAP) has been safely and effectively used to treat wound infections in different clinical indications. Thus, in this study we evaluated CAP therapy of superficial driveline infections (SDI). <h3>Methods</h3> 24 patients (20male, 4 female), who received a cfLVAD between 2012 and 2018, developed a SDI. In total 30 CAP plasma jet treatments were applied, 16 patients were treated in hospital, 8 patients in the ambulance and 6 patients were treated in both. All wounds were treated with CAP starting from the day of diagnosis of SDI. <h3>Results</h3> The average number of CAP applications per case was 9.06 times (1-101), median duration of hospital stay due to SDI was 41.35 days (5-254). 21 patients were additional treated with antibiotics (70%). In 9 patients (30%) an ascending driveline infection (ADI) occurred, which required surgical revision. The 3 month event free survival was 21 patients (70 %). There were no adverse side effects of CAP therapy observed and there were no abnormalities of cfLVAD during CAP treatment. <h3>Conclusion</h3> We demonstrate that CAP therapy could be effectively and safely applied in cfLVAD patients with SDI. Using CAP 70% of our cases with SDI were prevented from ADI. Future studies have to show if ambulant CAP therapy of superficial cfLVAD wound infections has the potential to prevent progression of infection or to avoid SDI infection at all.

Decreasing Driveline Infections in Patients Supported on Ventricular Assist Devices: A Care Pathway Approach

<h3>Purpose</h3> Driveline infections (DLIs) are a source of morbidity and mortality in patients on Ventricular Assist Devices (VADs) and pose a significant burden to the healthcare system. Using a Care Pathway (CP) to improve health outcomes, we aimed to reduce the incidence of DLIs and related hospital readmissions in patients on durable VADs. <h3>Methods</h3> This quality improvement project used the CP in all patients implanted from 08/18-07/19, with a 1-yr follow-up period for each patient. The CP focused on standardizing care at three time points: intra- and post-operative and discharge. Using statistical process control methods, DLIs and readmissions in the first-year post-implant were compared between those involved in the CP and those implanted between 01/17-07/18 (pre-CP). P-charts were used to detect special cause variation attributable to the implementation of the CP. <h3>Results</h3> There were 21 patients in the CP and 34 in the pre-CP group. A higher proportion of patients in the CP vs pre-CP group developed a DLI in the first year post-VAD implant (52% vs 32%) (See Figure). DLIs in patients in the CP occurred later post-implant [147 days (IQR 97, 280) vs 88 days (IQR 53, 202)] and a much smaller proportion of CP patients were readmitted to hospital for a DLI (55% vs 67%) within the first-year post-implant (Figure). <h3>Conclusion</h3> While the CP did not decrease the proportion of patients who developed a DLI within the first year post-VAD, there was a smaller proportion of patients who experienced a DLI-related readmission one year post-implant. This may suggest that the CP has played a role in decreasing the impact of DLIs in this patient population. However, given the small time period of follow-up for the CP patients, further data collection is needed to see if the changes in the processes of care of the CP had the desired beneficial effects.

Sex differences in continuous-flow ventricular assist device therapy for advanced heart failure.

The effect of patient sex in continuous-flow ventricular assist device (c-VAD) therapy has not been well described. We investigated sex-specific differences in clinical outcomes related to c-VAD therapy for Japanese patients. We retrospectively analyzed 153 patients, including 41 (27%) female patients who underwent c-VAD implantation over the last 13years in our institution for a mean follow-up of 766 ± 446days. Clinical outcomes were compared between male and female patients RESULTS: There was no significant difference in mortality, cerebral vascular accidents, the severity of heart failure, or driveline infection in patients who underwent c-VAD implantation, regardless of sex. While male patients tended to have more bleeding at the time of surgery, female patients had significantly higher rates of non-surgical bleeding during subsequent c-VAD therapy, mainly from gynecological origins. Female patients treated with c-VAD had a significantly higher incidence of non-surgical bleeding events. Careful attention to gynecological complications and sex-specific care is required in female patients with c-VAD.

Association of cigarette smoking and adverse events in left ventricular assist device patients.

Adverse events (AEs) associated with left ventricular assist devices (LVADs) cause significant morbidity and mortality. Little is known about patient-specific factors that contribute to rates of AEs. The purpose of this study was to assess the association of cigarette smoking history and AEs following LVAD implantation. This study was a single-center, observational examination of 355 consecutive patients who underwent continuous-flow LVAD implantation from May 1, 2008 to July 1, 2018. Based on self-report, 348 patients with available data were categorized as never, former, or current smokers. Pre-LVAD implantation baseline characteristics were obtained, and summary characteristics were calculated. Hospitalizations for gastrointestinal bleeds, driveline infections, strokes, pump thromboses, and acute heart failure were evaluated. The Cox proportional hazard model was used to estimate the association of smoking and AE-related hospital admissions. The cumulative incidence competing risk method was used for survival analysis. Current (8.22%, p 0.006) and former (4.75%, p 0.026) smokers had a greater proportion of admissions for pump thrombosis compared to never smokers (2.22%). Former smoking was associated with admission for driveline infection (HR 2.43, CI 1.08-5.46, p 0.03) on multivariate analysis. There were no significant associations between smoking and the other AEs of interest. There was no difference in survival among the three groups. Smokers had a higher proportion of admissions for pump thrombosis compared to never smokers, and former smoking was associated with admission for driveline infections in patients with LVADs.

Vasoplegia following heart transplantation and left ventricular assist device explant is not associated with inferior outcomes.

BackgroundVasoplegia has been associated with inferior outcomes following heart transplantation (HTx). This observational study was designed to investigate outcomes in recipients with vasoplegia following left ventricular assist device (LVAD) explant HTx.MethodsPatients undergoing LVAD explant followed by HTx from 01/2013–12/2018 at our centre were included. Vasoplegia was defined as the requirement for high dose vasopressor [noradrenaline (>0.5 μg/kg/min) and vasopressin (>1 U/h)] over the first 24 hours following HTx. Demographic and outcome data were retrieved from the transplant unit database.ResultsDuring the study period 24 patients underwent LVAD explant HTx. Of these, 13 (54.2%) developed vasoplegia. Both groups had similar duration of LVAD support (median 684 vs. 620 days P=0.62). There was a higher incidence of driveline infection in patients developing vasoplegia (69.2% vs. 18.2% P=0.02). HTx following donation after circulatory death (DCD) occurred in 9 (37.5%) patients and was not associated with a higher incidence of vasoplegia (P=0.21). Vasoplegia developed early following reperfusion and intensive care unit admission vasopressor-inotrope scores were significantly higher in patients with vasoplegia (P=0.002). Patients developing vasoplegia had similar ICU (P=0.79) and hospital (P=0.93) lengths of stay. Survival was equivalent both at 30-day (92.3% vs. 100% P=0.99) and 1-year (67.7% vs. 74.7% P=0.70). Our overall HTx 1-year survival was 89.3% over this period.ConclusionsVasoplegia is seen with a high incidence in HTx recipients bridged with an LVAD. This appears to be associated with the presence of driveline infections. Early aggressive management is advocated, resulting in equivalent 1-year survival to those patients not developing vasoplegia.

Application of an Absorbable Antimicrobial Mesh Reduces Major Driveline Infection in Chronic Mechanical Circulatory Support

Driveline infections (DLI), the main entity of VAD specific infections, in chronic mechanical circulatory support (MCS) increase with extended support times and contribute significantly to mortality and morbidity. The incidence of DLIs remains high at up to 30% at one year and often necessitate extensive surgical revisions, VAD exchange, or heart transplantation. Recently, an absorbable antimicrobial mesh impregnated with rifampin and minocycline (TYRX) was demonstrated to significantly reduce chronic implantable electric device infections. We evaluated the incidence of major DLIs in patients supported mechanically with or without the use of TYRX. Starting January 2015, 63 patients were supported by chronic MCS (HVAD: 60, HM3: 3) without TYRX use (group1); while starting December 2017, 56 patients were supported by chronic MCS (HVAD: 55, HM3: 1) with the additional use of TYRX to the driveline (group2). Operative technique and follow-up care remained unchanged. Major driveline infections were defined by the need of surgical revision, VAD exchange, heart transplantation, or life-time antibiotic treatment. Statistical significance was calculated by the log-rank test. In group 2, TYRX was tolerated in all 56 patients without any specific complication. Mean observation time was 891 days (37 to 1730) in group 1 and 285 days (40 to 679) in group 2. In group 1, 18 major DLI (28.6%) were documented at a mean of 459 days (23 to 1086) of support, and freedom of major DLI at one year was 84%. In group 2, 1 major DLI (1.8%) was detected at 291 days of support, and freedom of major DLI at one year was 96%. Comparison of the two groups reached statistical significance favoring TYRX use (p=0.045). In a single-center observation, additional wrapping of an absorbable antimicrobial mesh (TYRX) is safe, feasible, and significantly reduces the incidence of major driveline infection.

Prophylactic Use for Driveline Infections: Can we Prevent Infection Resulting from Trauma?

Driveline infections in patients with left ventricular assist devices (LVAD) have long been an adverse event that has been difficult to eliminate. Driveline infections lead to an increased morbidity and mortality and a decrease in quality of life for patients. This review served to determine if using antibiotics as prophylactic therapy can affect infection rates and increase survival in patients who have had trauma or manipulation of the driveline. Trauma or manipulation can consist of a controller drop, driveline tug. A retrospective chart review was done at a large academic medical center. We reviewed all patients implanted with an LVAD within the past 5 years. Patients were divided by infection vs non-infection; patients were then evaluated by who was treated with prophylactic antibiotic therapy and who developed an infection post antibiotic therapy compared to patients that developed an infection with no prophylactic therapy. We then reviewed survival rates within that cohort of patients. A total of 258 patients were evaluated for driveline infection. Of those, 73 (28%) patients had developed a driveline infection. Of those 73, 62 (84%) were not treated with prophylactic antibiotic therapy and 11 (15%) received prophylactic antibiotics. Mortality within the group of patients with no prophylaxis therapy was 25 (40%) vs 1 (9%) p=0.03 in the patients that were treated with prophylaxis antibiotic therapy. Prophylactic antibiotic therapy can be useful to prevent driveline infections and increase survival in patients with a known controller drop or driveline tug. Further studies should be done to evaluate further prophylactic antibiotic therapy in other cohorts of patients.

Clinical Strategies and Results of Medical Treatment and Surgical Reposition Technique for Driveline Infections in Patients with Continuous-Flow Left Ventricular Assist Devices

Continuous-flow left ventricular assist devices (cf- LVAD) driveline infection remains a significant limiting factor regarding patients' quality of life and overall long term outcome. This retrospective study investigates the single center strategy and outcome of cf-LVAD patients with driveline infection treated both medically or surgically. All patients treated for driveline infection on cf-LVADs from December 2014 to January 2019 in our center were analyzed. Baseline data was collected. Specific data included: time from cf-LVAD implantation to driveline infection, pathogen type, treatment strategy, time from diagnosis to surgical reposition. Usually, antibiotics were used as first line therapy. The surgical approach was chosen in resistant infections. Further topic of investigation was the freedom of reinfection in the follow up time. During the study period a total of 45 patients were treated with cf-LVAD implantation. 12 (26,6%) of the patients developed a driveline infection. Additionally, two patients with implanted cf-LVAD from outside center were admitted, increasing the total number of patients to n=14. The mean time from implantation till infection diagnosis was 16.53±14.27 months (range from 3.17 to 46.63). The majority (10 patients, 71.43%) ware treated with surgical reposition [Fig.1.] and 4 patients (28.57%) were treated only medically. In the reposition group, the time from diagnosis to treatment was 122.9±176.16 days (range from 5 to 554). Three patients were additionally treated with vacuum dressing. During the follow up time (14.16±16.22 months, range from 1.27 to 54.8) two patients treated surgically developed reinfection. Surgical reposition of cf-LVAD driveline is save and probably the only effective treatment for advanced infection. Skillful use of both antibiotic and surgical approach leads to excellent long term results in this patients cohort.

Cold Atmospheric Plasma for the Treatment of Superficial Driveline Infections in Patients with Left Ventricular Assist Devices

Despite all innovations in continuous flow left ventricular assist devices (cfLVAD) wound infections are still leading factors for morbidity and mortality in VAD patients. Over the last years, cold atmospheric plasma (CAP) has been safely and effectively used to treat superficial infections. Thus, in this study we present our results using CAP for the treatment of superficial driveline infections (SDI). We describe a two center experience with 25 patients (21male, 4 female) and 32 treatments, who were implanted between 2012 and 2018 and developed a SDI in the follow up. 17 cases were treated inhospital, 9 in an outpatient clinic and 6 were treated in both. All wounds were treated with CAP (kinPen MED) starting from the day of diagnosis. The average number of CAP applications per case was 11.2 times (1-49), median duration of hospital stay due to SDI was 25 days (5-106). 19 cases were additional treated with antibiotics (59%). In 9 cases (28%) occurred an ascending driveline infection (ADI) requiring surgical revision. The 3 month event free survival was 23 cases (72 %). There were no adverse side effects of CAP therapy observed and there were no abnormalities of cfLVAD during CAP treatment. In our study we demonstrate that CAP therapy could be effectively and safely applied in cfLVAD patients with SDI. Using CAP 72% of our cases with SDI were prevented from ADI. Future studies have to show if ambulant CAP therapy of superficial cfLVAD wound infections has the potential to prevent progression of infection or to avoid SDI infection at all as prophylactic therapy.

Driveline-related infections after left ventricular assist device implantation: A single center experience

Amaç: Sol ventrikül destek cihazı sonrası görülen en sık komplikasyon driveline kaynaklı enfeksiyonlardır. Bu komplikasyon hastaların hayat kalitesini ileri derecede bozmaktadır. Bu çalışmanın amacı sol ventrikül destek cihazı takılan hastalarda driveline enfeksiyonlarını araştırmak ve tedavi stratejimizi ortaya koymaktır. Gereç ve Yöntemler: Mayıs 2013 ile Ekim 2018 tarihleri arasında sol ventrikül destek cihazı takılan 90 erişkin hasta çalışmaya dahil edildi. Driveline enfeksiyon oranları, özellikleri, patojen mikroorganizmalar araştırıldı. Ayrıca enfeksiyonlara karşı uygulanan tedavi seçenekleri incelendi. Bulgular: Hastaların ortalama yaşları 46,3 ± 13,7 idi ve %83,3’ ü (75/90) erkekti. Hastaların %62,2’ sinde dilate kardiyomiyopati mevcuttu. Tüm hastaların %35,5’inde (32/90) driveline enfeksiyonu tespit edildi. İmplantasyon ve driveline enfeksiyonu görülme arasında geçen ortalama süre 304±309(15-1500) gündü. Alınan sürüntü ve/veya doku kültürlerinde en çok tespit edilen mikroorganizmalar gram pozitif koklar idi. Yedi hastada oral antibiyotik, 25 hastada ise hastaneye yatırılarak sistemik antibiyotik tedavisine gereksinim duyuldu. On üç hastada oral/sistemik antibiyotik tedavisi ile enfeksiyon kontrol altına alırken 15 hastada ise cerrahi olarak debridman yapıldı, üç hastada driveline daha yukarı bir bölgeye taşındı ve bir hastaya kalp nakli gerekti. Hiçbir hastada cerrahi olarak cihazın çıkarılmasını gerektirecek kontrolsüz enfeksiyona rastlanmadı. Sonuç: Sol ventrikül destek cihazları yüksek oranda driveline enfeksiyonu oranlarına sahiptir; bu çalışmada oran 1. yılda %24,4 olarak bulunmuştur. Oral veya sistemik antibiyotik tedavisi ile ve/veya seçilmiş vakalarda debridman tedavisi ile enfeksiyon kontrol altına alınmış, nadiren driveline kablosunun taşınması ve kalp nakline ihtiyaç duyulmuştur.

Role of Gallium-SPECT-CT in the Management of Patients With Ventricular Assist Device-Specific Percutaneous Driveline Infection

Percutaneous driveline infection is a major complication of left ventricular assist device (LVAD). This study evaluated the role of gallium-67 single-photon emission computed tomography (Ga-SPECT)-CT in LVAD-specific percutaneous driveline infection. Thirty-six patients with implantable continuous-flow LVAD, who underwent Ga-SPECT-CT to evaluate percutaneous driveline infections, were enrolled and divided into uptake and no-uptake groups based on tracer concentration uptake on Ga-SPECT-CT. Primary outcomes were surgical intervention and readmission for driveline infection. Twenty-two patients had uptake on Ga-SPECT-CT. No significant differences were noted in patient characteristics, wound appearance, or laboratory results. The prevalence of positive skin culture at the driveline exit site (DLES), and usage and duration of antibiotics did not differ. However, the uptake group had higher 1-year event rates (surgical intervention: 39% vs 0%, P = .019; readmission: 74% vs 6.9%, P = .0016). In addition to positive skin culture at DLES and short duration of antibiotic therapy, uptake on Ga-SPECT-CT was a risk factor for surgical intervention (odds ratio 9.00; P = .018) and readmission (odds ratio 7.86; P = .0051). Ga-SPECT-CT could be one of the clinical modalities for guiding the treatment of driveline infection in patients with a LVAD.

Driveline angle is crucial for preventing driveline infection in patients with HeartMate II device.

We hypothesized that the externalizing direction of the driveline (the driveline angle) at the percutaneous exit site would influence the occurrence of driveline infection after left ventricular assist device implantation. From August 2013 to May 2017, 71 patients were implanted with a HeartMate II device in our center. The driveline angle was measured on anteroposterior radiography just after implantation. Risk factors for driveline infection were analyzed by uni- and multivariate analyses. Driveline infection developed in 10 (14%) patients during follow-up. Overall actual freedoms from driveline infection at 6, 12, and 24months were 96%, 88%, and 86%, respectively. Overall number of driveline infection events per patient-year was 0.16. Receiver operating characteristic analysis determined the cut-off point of the driveline angle as 41°. The 6-, 12-, and 24-month actuarial freedoms from driveline infection in those with driveline angle more than 42° (84%, 74%, and 74%, respectively) were significantly lower than in those with driveline angle less than 41° (97%, 94%, and 90%, respectively; p < 0.02). The numbers of driveline infection events per patient-year were 0.16 in patients with driveline angle more than 42°, and 0.04 in patients with driveline angle less than 41°. Multivariate analysis demonstrated that driveline angle more than 42° was an independent risk factor for driveline infection (hazard ratio 4.71). Driveline angle more than 42° is an independent risk factor for driveline infection in patients with HeartMate II. Externalization of the driveline toward the horizontal direction is important to prevent driveline infection with HeartMate II.

Surgical management of driveline infections in patients with left ventricular assist devices.

Driveline infections in patients with implantable left ventricular assist devices (VAD) carry increasing risk for pump infection, thromboembolic events, decreased quality of life, and increased hospitalization. We report our experience with a surgical technique for refractory driveline infections without mediastinitis consisting of translocation and wrapping of the driveline with greater omentum tissue. We retrospectively reviewed data of VAD patients who underwent surgical treatment by translocation and wrapping with omentum for severe chronic driveline infection. Thirteen patients were treated between January 2010 and October 2015; 12 (92%) were male, and the mean age was 56 ± 14 years. Ten patients (77%) were managed with driveline sheathing with omentum and repositioning with a new exit site, and three (23%), suffering from driveline fistula, with driveline covering with omentum maintaining the previous exit site. Three episodes of postoperative bleeding (23%) required surgical revision. Twelve patients (92%) were discharged from the hospital and one (8%) died. Nine patients (69%) were free from infection at the time of discharge, and three (23%) had recurrence of infection within the first postoperative year. Only four patients (31%) required admission to the intensive care unit; overall median hospital stay was 23 days (range 7-205 days). Driveline relocation with use of omentum is a feasible and effective procedure in selected cases of chronic severe driveline infection. The risk for perioperative bleeding should be taken into consideration and carefully monitored.

Topical Polymyxin-Trimethoprim Prophylaxis May Decrease the Incidence of Driveline Infections in Patients With Continuous-Flow Left Ventricular Assist Devices.

This retrospective cohort study evaluated the effect of topical polymyxin-trimethoprim (poly) prophylaxis on the incidence of driveline infections (DLIs) in patients with continuous-flow left ventricular assist devices. All 84 cases implanted 2005-2014 with device support ≥30 days were reviewed; support ranged 1 m-5.2 yrs. Beginning 2008, poly was applied to the exit site with dressing changes. Sixty-five patients received poly (poly group) for duration of follow-up, 19 did not (no-poly); group baseline characteristics were similar. No patient developed side effects from poly. Nineteen DLIs (10 in no-poly) occurred; not using poly was a risk factor. 89% of poly group DLIs were superficial, 4 were culture-negative. DLI-related bacteremia occurred in 11% of no-poly group and 0% of poly group. Compared with no-poly, poly group demonstrated improved freedom from DLI by Kaplan-Meier analysis (P < 0.0001) and a 75% lower overall and 95% lower deep DLI incidence (P ≤ 0.001). Deep DLIs occurred in 31.6% of no-poly vs. 1.5% of poly patients (P = 0.0004), although mean support duration (1 yr) and % support >1 yr (38%) were similar. These findings, which should be confirmed with larger comparative studies, suggest that topical polymyxin-trimethoprim prophylaxis may be effective in preventing DLIs.