VAD-related Infections Research Articles

Epidemiology and Risk Factors for Nosocomial Infections in Left Ventricular Assist Device Recipients.

Left ventricular assist devices (LVADs) have been increasingly used as a valid option to improve the prognosis and reduce the symptoms of end-stage heart failure. However, long-term complications, mostly infections and coagulation disorders, are frequent. We described the epidemiology and risk factors for nosocomial infections (NIs) in a cohort of adult patients who underwent continuous-flow LVAD implant between January 2010 and December 2017 in Turin, Italy. Secondary outcomes were the prevalence of multidrug-resistant (MDR) bacteria and mortality. Results: Overall, 64 LVADs were implanted. A total of 32 (50%) patients experienced at least one episode of NI, with a total of 46 infectious events. VAD-related infections occurred in 22 patients (68.8%). Non VAD-related NIs occurred in 12 patients (37.5%), mainly low respiratory tract infections. Length of intensive care unit admission was a risk factor for NI (OR 1.224, 95%CI; 1.049, 1.429). Gram-negative bacilli were responsible for 58.8% of VAD-related infections and 79.5% of non-VAD related infections. In sixteen patients (50%), at least one episode of infection was related to an MDR strain. INTERMACS class and length of MV were independent risk factors for NIs by MDR strains (respectively, OR 2.12, 95%CI: 1.08, 6.80; p = 0.02 and OR 1.46, 95%CI: 1.07, 5.52, p = 0.047). In-hospital mortality was 6.3%. No differences in mortality were observed between infected and non-infected patients (p = 0.61) even when caused by MDR strains (p = 0.143). Conclusion: the rate of nosocomial infections in LVAD patients is associated with the length of ICU admission, and the etiology of nosocomial infection after LVAD implant is mainly due to GNB, including a high rate of MDR strains, especially KPC-KP and MDR PA.

2021. Efficacy of Chronic Antimicrobial Suppressive Therapy in Ventricular Assist Device Infections

Abstract Background Ventricular assist devices (VAD) prolong life expectancy or serve as a bridge to heart transplant in end stage heart failure but are not without risks. These patients are at high risk for device-related infections with a propensity for relapse. Indications and efficacy of chronic antimicrobial suppression (CAS) to prevent relapse are not well defined. Methods We conducted a retrospective study of all adult patients with VAD infections at our institution between 1/1/2013 and 10/31/2020. VAD-specific or VAD-related infections were defined by the International Society for Heart and Lung Transplantation criteria. Patients were stratified by receipt of CAS or no CAS after completing index infection treatment. Relapsed infections were defined as those recurred at the same site caused by the same organism seen in the index infection. Time-to-relapse infection was defined as the time in days between the index infection and first relapse. The primary outcome was CAS efficacy measured by time-to-relapse in VAD-specific or -related infections. Results A total of 83 patients were included with a documented VAD-specific (n = 68) or VAD-related (n = 15) infection. Driveline (n = 66) and bloodstream (n = 13) infections were the most common VAD-specific and VAD-related infections, respectively. For the index infection, all patients received antimicrobial treatment and 16.4% required incision and drainage. Staphylococcus aureus was most frequently isolated in 46 cases. Oral minocycline was the most commonly utilized agent in 22 of 47 patients receiving CAS. Agent-specific CAS efficacy was unable to be assessed due to the small sample. In patients who received CAS, 57% experienced a relapse infection compared to 81% in patients not receiving CAS (p = 0.03). The median time to relapse was 151 days (IQR 78-247) and 57 days (IQR 36-114) in the CAS and non-CAS groups, respectively (p < 0.01). Conclusion The incidence of relapse infection in the setting of CAS was lower compared to those not receiving CAS. Patients receiving CAS were relapse-free for a significantly longer duration. Larger studies are warranted to assess if one agent confers a benefit over another. Disclosures M. Rizwan Sohail, MD, Aziyo Biologics: Honoraria|Boston Scientific Corporation: Honoraria|Medtronic: Grant/Research Support|TRYX: Grant/Research Support.

Abstract 10230: Epidemiology of Early and Late Ventricular Assist Device Infections in Bridge-to-Transplant Patients: A Single Centre Experience

Introduction: Bacterial infections are common after ventricular assist device (VAD) implantation. Better understanding of their epidemiology in bridge-to-transplant (BTT) pts will allow for improved infection prevention, management, and optimization for transplantation. Methods: We performed a retrospective cohort study of 42 BTT pts with VAD infections from 4/2006-10/2020. VAD-specific and VAD-related infections were characterized according to 2011 ISHLT definitions. Infections were classified as early if occurring ≤ 90 days, and late if occurring >90 days after VAD implantation. Results: The prevalence of VAD infections among BTT pts was 23%, with 24% of those occurring early and 76% occurring late. Pts with infections were predominantly male (n=32, 76%) and white (n=30, 71%), with non-ischemic cardiomyopathy (n=22, 52%), and mean age at implantation of 52.7y. There were no significant differences in baseline characteristics between pts who developed early or late VAD infections (Table 1). Pts had VAD infections involving the bloodstream (n=22), driveline (n=22), pump (n=9), and pocket (n=3), with an additional 10 pts with possible endocarditis and 3 with sternal infections/mediastinitis. Most superficial driveline infections occurred more than 90 days after implantation (19 vs. 1, p=0.029). There were no significant differences in the incidence of early and late infection for the remainder of VAD-related infections reviewed (Table 2). Gram-negative organisms were responsible for the most infections (n=15), followed closely by Staphylococcus aureus (n=14); there was no significant difference in organisms causing early vs. late infection (Table 3). Conclusions: In this single center study of BTT pts over a 14-year period, superficial drive-line infections rarely occurred in the first 90 days post-VAD implantation. Gram-negative rods and Staphylococcus aureus were nearly equally responsible for most infections.

Left ventricular assist device-related infections and the risk of cerebrovascular accidents: a EUROMACS study.

OBJECTIVESIn patients supported by a durable left ventricular assist device (LVAD), infections are a frequently reported adverse event with increased morbidity and mortality. The purpose of this study was to investigate the possible association between infections and thromboembolic events, most notable cerebrovascular accidents (CVAs), in LVAD patients.METHODSAn analysis of the multicentre European Registry for Patients Assisted with Mechanical Circulatory Support was performed. Infections were categorized as VAD-specific infections, VAD-related infections and non-VAD-related infections. An extended Kaplan–Meier analysis for the risk of CVA with infection as a time-dependent covariate and a multivariable Cox proportional hazard model were performed.RESULTSFor this analysis, 3282 patients with an LVAD were included with the majority of patients being male (83.1%). During follow-up, 1262 patients suffered from infection, and 457 patients had a CVA. Cox regression analysis with first infection as time-dependent covariate revealed a hazard ratio (HR) for CVA of 1.90 [95% confidence interval (CI): 1.55–2.33; P < 0.001]. Multivariable analysis confirmed the association for infection and CVAs with an HR of 1.99 (95% CI: 1.62–2.45; P < 0.001). With infections subcategorized, VAD-specific HR was 1.56 (95% CI: 1.18–2.08; P 0.002) and VAD-related infections [HR: 1.99 (95% CI: 1.41–2.82; P < 0.001)] remained associated with CVAs, while non-VAD-related infections (P = 0.102) were not.CONCLUSIONSInfection during LVAD support is associated with an increased risk of developing an ischaemic or haemorrhagic CVA, particularly in the setting of VAD-related or VAD-specific infections. This suggests the need of a stringent anticoagulation management and adequate antibiotic treatment during an infection in LVAD-supported patients.

Extended systemic antibiotic prophylaxis in ventricular assist device recipients, an infectious disease perspective

To evaluate whether mediastinitis/deep sternal wound infection (Med/DSWI) is more common in ventricular assist device (VAD) with delayed sternal closure (DSC) compared to VAD with primary sternal closure (PSC). A literature search was done over the last four decades for studies that addressed this comparison. Two studies met our inclusion criteria, and their results are contradictory. The first study compared 184 VAD recipients with PSC to 180 VAD recipients with DSC. There was no difference in VAD-related infections between DSC and PSC (15% vs. 16%, respectively; odds ratio = 0.965, 95% confidence interval [CI] = 0.525-1.635). The second study compared 464 VAD recipients with PSC to 94 VAD recipients with DSC. The rate of surgical site infection was higher in the DSC patients (12.5% vs. 1.4%, respectively; odds ratio = 10.1; 95% CI = 3.8-27.0). DSC was identified as an independent risk factor for postoperative mortality, but no detailed infection information was given. There is no clear evidence of the association between DSC, compared to PSC, and Med/DSWI. Therefore, DSC is not an absolute indication for extended systemic antibiotic prophylaxis. The decision to extend the duration of systemic antibiotic prophylaxis should be made on a case-by-case basis, in collaboration with an infectious disease specialist.

VAD related infections and the risk of pump thrombosis and thromboembolic events: a EUROMACS study

Abstract Background In patients supported by a ventricular assist device (VAD) major infections are a frequently reported adverse event with increased morbidity and mortality. Purpose The purpose of this study was to investigate the possible association between infections and cerebrovascular accidents (CVAs) in VAD patients. Methods An analysis of the European Registry for Patients Assisted with Mechanical Circulatory Support (EUROMACS) was performed identifying all patients aged ≥18 years with a LVAD or BiVAD implantation. Infections were categorized as VAD-specific infections, VAD-related infections and, non-VAD infections. An extended Kaplan-Meier analysis for the risk of CVA and mortality with infection as a time-dependent covariate was performed. Furthermore, a multivariable Cox proportional hazard model was performed including 24 variables. Results For this analysis 3784 patients were included, with 45 patients being supported by a BiVAD and 3739 by an LVAD. The majority of patients were male (83.2%) and 60.5% had an INTERMACS patient profile 2 or 3. During follow-up, 3108 major infections were identified in 1385 (36.6%) of the patients, while 673 CVAs were identified in 545 (14.4%) of the patients. Extended Kaplan-Meier analysis with first infection as time-dependent covariate revealed a hazard ratio (HR) for CVA of 1.95 (95% CI: 1.57–2.36; p&amp;lt;0.005) (Figure) and 1.50 (95% CI: 1.33–1.68, p&amp;lt;0.005) for mortality. Multivariable analysis confirmed a significant association for infection and CVAs with a HR of 1.46 (95% CI: 1.29–1.64). With infections subcategorized, VAD-specific (HR: 1.57 (95% CI: 1.18–2.09)) and VAD-related infections (HR: 2.04 (95% CI: 1.44–2.89)) remained significantly associated with CVA but non-VAD infections (HR: 1.22 (95% CI: 0.92–1.64)) were not. Conclusion Both VAD-related and VAD-specific infections are associated with a significantly increased risk of CVA with increased risk of mortality. Funding Acknowledgement Type of funding sources: None. KM freedom of CVA and infection

Mortality Following Durable Left Ventricular Assist Device Implant by Timing and Category of First Infection

<h3>Purpose</h3> While infections are common following left ventricular assist device (LVAD) implant, the relationship between timing and category of first infection and mortality is less well understood. <h3>Methods</h3> STS Intermacs patients (>19 yrs) receiving a primary, durable continuous flow LVAD from 4/2012 to 5/2017 were included. The primary exposure was defined in 3 ways: any infection, timing of first post-implant infection (early: <90d, intermediate: 90-180d, late: >180d), and first infection category (VAD-specific, VAD-related, non-VAD). Cox proportional-hazards regression models were used to estimate the association between first infection and all-cause mortality, adjusting for comorbidities & post-implant stroke. <h3>Results</h3> A total of 12,957 patients (228,742 person-months of follow-up) were implanted (DT: 47.4%, BTT: 41.2%) at 166 centers. First infections were most often non-VAD (54.2%), followed by VAD-specific (25.4%) & VAD-related (20.4%). Rates of first infection (per 100 person-months) were highest in the early interval (10.7) vs intermediate (3.7) or late (2.7), p<0.001. Relative to patients without infection, patients with any infection had a significantly higher hazard of death (HR 3.46). First infection in the intermediate interval following implant was associated with the largest increase in hazard of death (HR 3.97), followed by late (HR 3.65) and early intervals (HR: 3.31). VAD-related infections were associated with the largest increase in hazard of death (HR 4.04) followed by non-VAD (HR 3.34), and VAD-specific infections (HR 3.23). <h3>Conclusion</h3> First infections were most often non-VAD-related and rates were highest early after implant. VAD-related infections and infections occurring in the intermediate interval were associated with the largest increase in hazard of death. A mixed-methods evaluation could explore these findings at the institutional level and why these patterns occur.

LVAD- Antibiotic and Warfarin Alert

<h3>Introduction</h3> Three of the main causes of early and late morbidity and mortality in Ventricular Assist Device (VAD) recipients include infections, bleeding and thrombosis. Infections directly or indirectly associated to VAD are common and often requiring prolonged courses of intravenous antibiotics. Anti-vitamin K anticoagulants are known to interact with many drugs including antimicrobial agents. This case report highlights the risks of an important drug-drug interaction that has the potential to result in serious consequences. <h3>Case Report</h3> A 45-year-old male with LVAD (HeartWare) presented with an episode of significant hypotension (MAP 40mmHg) and was admitted to the Intensive Care Unit and initiated on vancomycin and Tazocin for empiric coverage of a suspected VAD-related infection. He was subsequently diagnosed with a methicilin sensitive Staphylococcus aureus (MSSA) bacteraemia. Vancomycin was changed to I-V flucloxacillin 8 g daily. No clear source of sepsis was demonstrated and a transoesophageal echocardiogram did not reveal vegetations. In the context of sepsis, the patient's INR initially increased to 3.7. Subsequently, his INR decreased despite dramatic increases in warfarin dosing up to 22mg. He was discharged home on IV flucloxacillin. 14 doses of low molecular weight heparin and an increase of 250% of warfarin (from 7mg to 17mg average) were necessary. It was only with close home monitoring that we were able to detect this significant interaction and prevent serious complications. <h3>Summary</h3> Flucloxacillin can reduce the anticoagulant effect of Vitamin K Antagonists. The literature about this interaction is scarce. One possible mechanism is induction of CYP3A4-mediated metabolism of R-warfarin by Flucloxacilin via Pregnane-X hormone receptor upregulation resulting in reduced warfarin concentrations and effects. This case report raises concerns about antibiotic therapy in VAD patients. It is important to be aware of this potentially serious interaction and close INR monitoring is recommended.

Gallium-67 Single-Photon Emission Computed Tomography Affects Management of Infections of Left Ventricular Assist Devices.

Our institution employs gallium-67 single-photon emission computed tomography low-dose CT (Ga-SPECT-CT) to determine the presence and extent of left ventricular assist device (LVAD) infections. We present a retrospective single-center study of 41 LVAD recipients who underwent Ga-SPECT-CT from January 2011 to June 2018 to determine whether Ga-SPECT-CT led to changes in antimicrobial therapy, LVAD revision or exchange, or application for 1A exception. The average age was 56.6 years, predominantly male (80.5%) and diabetic (68.3%), divided between ischemic (48.8%) and nonischemic (51.2%) cardiomyopathy. The majority had HeartMate II devices (82.9%). Device-related infections were classified as possible (12.2%), probable (36.6%), proven (36.6%), or rejected (14.6%). Sensitivity was 68.6% and specificity was 100%. Most VAD-specific infections were percutaneous deep driveline infections (DRIs) (34.1%), and VAD-related infections were primarily bloodstream infections (31.7%). Staphylococcus aureus was the major pathogen isolated. Gallium-67 single-photon emission computed tomography low-dose CT resulted in changes in management in more than half (53.7%) of patients: starting (24.4%) or stopping (17.1%) antimicrobial therapy, LVAD revision (22.0%) or exchange (12.2%), and the application for 1A exception for transplant listing (17.1%). We conclude that Ga-SPECT-CT is an effective modality for determining the presence and extent of LVAD DRIs, and contributed to a change in management in more than half of cases.

VAD-Related and Specific Infections are Significantly Associated with an Increased Risk of Cerebrovascular Accidents in Patients Supported by a Ventricular Assist Device: An EUROMACS Analysis

In patients supported by a ventricular assist device (VAD) major infections are a frequently reported adverse event with increased morbidity and mortality. The purpose of this study was to investigate the possible association of infections and cerebrovascular accidents (CVAs). An analysis of the European Registry for Patients Assisted with Mechanical Circulatory Support (EUROMACS) was performed identifying all patients aged ≥18 years with a LVAD or BiVAD implantation. Infections were categorized as VAD-specific infections, VAD-related infections and non-VAD infections. An extended Kaplan-Meier analysis for the risk of CVA and mortality with infection as a time-dependent covariate was performed. Furthermore, a multivariable cox proportional hazard model was performed including 24 variables. For this analysis 3784 patients were included, with 45 patients being supported by a BiVAD and 3739 by an LVAD. The majority of patients were male (83.2%) and 60.5% had an INTERMACS patient profile 2 or 3. During follow-up, 3108 major infections were identified in 1385 (36.6%) of the patients, while 673 CVAs were identified in 545 (14.4%) of the patients. Extended Kaplan-Meier analysis with first infection as time-dependent covariate revealed a hazard ratio for CVA of 1.95 (95% CI: 1.57-2.36; p < 0.005) (Figure) and 1.50 (95% CI: 1.33-1.68, p < 0.005) for mortality. Multivariable analysis confirmed a significant association for infection and CVAs with a HR of 1.46 (95% CI: 1.29-1.64). With infections subcategorized, VAD-specific (HR: 1.57 (95% CI: 1.18-2.09)) and VAD-related infections (HR: 2.04 (95% CI: 1.44-2.89)) remained significantly associated with CVA but non-VAD infections (HR: 1.22 (95% CI: 0.92-1.64)) were not. Both VAD-related and VAD-specific infections are associated with significant increased risk of CVA, but non-VAD infections are not.

Risk Factors for Fungal Infection in a Ventricular Assist Device Cohort

Ventricular assist device (VAD) infections are an important cause of morbidity and mortality. Fungal infections are associated with poor outcomes and risk factors to predict infection warrant characterization. A retrospective cohort study of continuous-flow 2nd or 3rd generation VAD devices placed at Northwestern Memorial Hospital from July 2008 to September 2018 was performed. VAD-specific and VAD-related infections were characterized according to 2013 ISHLT definitions. Early infections were defined as occurring less than or equal to 60 days from the date of VAD implantation, late infections were defined as greater than 60 days. Binary logistic regression analysis comparing fungal to non-fungal bacterial infections identified significant risk factors. Summary and comparative statistics were performed using IBM® SPSS Statistics version 25.0. 86 infections occurred in 433 VAD implantations. 93.0% (n = 80) were non-fungal and 7.0% (n = 6) were fungal. Independent risk factors for fungal infection when compared to bacterial infections were early VAD infection (66.6% vs 11.3%, p = 0.000), ischemic cardiomyopathy as an underlying diagnosis (83.3% vs 38.7%, p = 0.033), 3rd generation VAD device (100% vs 53.7%, p = 0.027), polymicrobial infection (83.3% vs 28.8%, p = 0.006), concurrent infection with a multi-drug resistant organism in the same device (66.6% vs 21.2%, p = 0.013) as shown in Table 1. Patients with fungal infections had a higher mortality rate (66.6% vs 27.5%, p = 0.044). Risk factors for fungal infection compared to bacterial infections in VADs are ICM, 3rd generation devices, polymicrobial infection, and concurrent MDRO infections. Mortality is higher in VAD patients with fungal infections.

Incidence of Infection and Antimicrobial Consumption in Ventricular Assist Device (VAD) Recipients at the Prince Charles Hospital (TPCH): A Retrospective Analysis

Ventricular assist devices (VADs) are frequently used as a bridge to heart transplant; however, infections are a common cause of increased morbidity and mortality. The optimal prophylactic antimicrobial regimen has not been effectively evaluated in literature. Forty-three (43) patients received a VAD over the 5-year study period (2012-2017) at The Prince Charles Hospital (TPCH), Brisbane Australia. Of these, 41 patients were followed from implantation until transplantation or death. Antimicrobial prophylactic regimens and individual episodes of infection were recorded. The infection profiles, including types and incidence were compared to published literature using definitions from the International Society for Heart and Lung Transplantation (ISHLT) guidelines for consistency. Median duration of VAD insertion was 79 days (IQR: 36-167). Patients received aztreonam, fluconazole and vancomycin (median duration 8 days). Twenty-two (22) (53.6%) patients experienced a VAD-specific and/or a VAD-related infective episode. Incidence of infection in the study cohort was 0.60 infections per 100 patient days. Thirteen (13) patients (31.7%) experienced 16 VAD-specific infections which were all driveline infections. Thirteen (13) patients (31.7%) experienced 14 VAD-related infections. The predominant VAD-related infection type was bacteraemia (36%). Predominant bacterial profiles of VAD-specific as well as VAD related infections were gram positive. Only three episodes had a gram negative as a causative pathogen which occurred much later post VAD insertion. Median time till VAD-specific or VAD-related infection was 46 and 15 days respectively. Obesity was significantly associated with increased risk of infection (HR: 3.2; 95% CI: 1.3-7.4). Infection is a common complication of VAD implantation. In our study population gram positive bacteria were the predominant causative pathogen. Based on the micro-organism profile there may be scope for a narrowing of the antibiotic regimen. A larger, multicentre study would be able to accurately guide a change. The information gathered in our study offers a strong foundation for such a multicentre study.

Epidemiology of Left Ventricular Assist Device Infections: Findings From a Large Nonregistry Cohort.

Infection is a major complication during circulatory support with a left ventricular assist device (VAD). Changes in device characteristics and treatment practices in the last decade can affect the epidemiology of infection. The International Society for Heart and Lung Transplantation (ISHLT) has published recommendations on the prevention and management of VAD infections, but data to support these recommendations remain sparse. We performed a retrospective review of 455 patients who underwent VAD placement from 2009 to 2015. Infection episodes were defined using ISHLT criteria and were also grouped as endovascular or local. Analysis included descriptive statistics. There were 174 patients (38.6%) with a VAD infection. Infection incidence was 36.9 cases per 100 person-years of VAD support. The driveline was the most common infection site (67.2%). Systemic inflammatory response syndrome (SIRS) criteria were not satisfied in 29.2% of patients with endovascular infections, and computed tomography (CT) examinations were normal in 37.7% of cases. Gram-positive bacteria caused 65.6% of infections in patients with an available culture. Antimicrobial suppression was used in 72.3% of patients who survived treatment. Median survival after infection was 35 months for patients with VAD-related infections versus 14 months for patients with VAD-specific infections. VAD infections continue to be a major complication after implantation. Clinical criteria alone were not predictive of serious infections, and many patients with confirmed infection had normal CTs. Patients with VAD-specific infections had lower median survival than patients with VAD-related infections.

1180. Colonization with Multidrug-Resistant Organisms Is Associated with Subsequent Infection in the Ventricular Assist Device Population

BackgroundInfection is a leading cause of morbidity and mortality in the ventricular assist device (VAD) population. We performed a retrospective cohort study outlining the epidemiology of multidrug-resistant organism (MDRO) colonization and infection rates in this population.MethodsWe performed a longitudinal retrospective cohort of all patients receiving continuous-flow (axial and centrifugal) ventricular assist devices from July 2008 to September 2018 at Northwestern Memorial Hospital. Peri-operative prophylaxis from July 2008 to June 2013 was vancomycin, rifampin, ciprofloxacin, and fluconazole, and vancomycin plus cefuroxime from June 2013 to September 2018. VAD-specific and VAD-related Infections were classified according to ISHLT 2013 definitions. Patients were screened for methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis or Enterococcus faecium, or extended-spectrum β-lactamase producing Gram-negative rods. Statistics were performed using IBM® SPSS Statistics version 25.0. Comparative statistics were performed using two-sided Fisher’s exact test with a P-value of <0.05 deemed significant.ResultsA total of 89 patients with ventricular assist devices developed either VAD-specific or VAD-related infections and were included in the analysis. 77% of patients (n = 66) were colonized with an MDRO; 29% (n = 25) with MRSA, 73% (n = 63) with VRE, and 24% (n = 21) with an ESBL organism. 17.9% (n = 16) of patients who went on to develop infection was secondary to MDROs. Colonization with an MDRO was associated with subsequent infection secondary to these organisms (P = 0.018).ConclusionColonization rates of multidrug-resistant organisms in the VAD population are high. VRE rates were significantly higher than MRSA or ESBL, possible as a result of peri-implantation utilization of vancomycin as surgical site prophylaxis. MDRO colonization was associated with progression to VAD-specific or VAD-related Infection.Disclosures All authors: No reported disclosures.

A New Less Invasive Technique of RVAD Insertion - Time to Lower the Threshold around LVAD Insertion

Purpose Temporary mechanical Right Ventricle(RV) support around planned LVAD implantation has always carried a substantial risk of mortality and morbidity. Historically insertion and removal of RVAD have been highly invasive. We use a less invasive variation of RV support concomitant with LVAD implantation. Methods Retrospective review of patient records who underwent temporary RVAD insertion along with LVAD insertion. The inflow cannula is an 8mm vascular graft on to the main pulmonary artery which is brought out through the second intercostal space and tunneled again under the skin for 10cm before the cannula exits. The drainage cannula could be in the neck or groin. A 25 Fr. cannula is inserted into the Right Internal Jugular Vein or the stump of the Saphenous Vein. When the RV has recovered, under the local anaesthesia the vascular graft is tied and the venous cannula is removed respectively. Results Over the past 3 years, 71 patients have undergone LVAD insertion (HVAD, Heartware II) at our institute; out of whom 14 (19.7%) required temporary RVAD support. The majority of these patients were male (78.5%) with a mean age of 49.7±12.2 years. 42.8 % of the patients had ischaemic cardiomyopathy, 35.7% had dilated cardiomyopathy and 21.4% had viral myocarditis. Most of the patients had deranged RV parameters preoperatively. Temporary RVAD support was instituted if the patient could not be weaned off Cardiopulmonary Bypass or had poor LVAD flows despite optimal inotropic support. The neck venous cannulation allowed for early patient mobilisation while still on the RVAD. The average duration of RVAD support was around 8.7±4.4 days. It is our standard practice to extubate patients while on RVAD, aggressively remove fluid either with Continuous Veno-Venous Haemofilteration or diuresis and inotropic support with a combination of Milrinone, Adrenaline and Levosimendan. We were able to successfully wean off, all our 14 patients from RVAD. Our long term follow-up reveals that 11 out of 14 patients (78.5%) are still alive and healthy. Two of these patients have already had their heart transplanted and the rest are enlisted for heart transplantation. We unfortunately lost 3 of the 14 patients - one each to VAD thrombosis, VAD related infection and multiorgan failure Conclusion Experience with this technique is highly encouraging and we plan to undertake a prospective study to validate this.

Efficacy of Pump Exchange with a Left Ventricular Assist Device Associated Infection

Purpose Left ventricular assist device (LVAD) exchange for source control of infection has been suggested as a treatment option for LVAD-associated infections (LVADI). However, there are limited data regarding the efficacy and outcomes of these patients. We reviewed the clinical outcomes of patients undergoing a device exchange in the presence of persistent and severe VAD-specific and VAD-related infections. Methods We retrospectively reviewed all patients (n=80) at our center who underwent a CF-LVAD exchange between January 2005 and October 2016. Patients with a LVADI, defined using the International Society of Heart and Lung Transplant criteria were further evaluated. The primary outcomes included freedom from recurrent or new LVADI and survival at 1 and 2 years following pump exchange. Results A total of 31 (39% of 80) patients had a LVADI at time of device exchange. Median age was 59 years, 25 (81%) male, 26 (84%) HeartMate 2, and 29 (94%) destination therapy. Indication for exchange was 9 (29%) infection, 10 (32%) hemolysis, and 12 (39%) device failure. Median duration of support prior to infection was 1.1 years (range, 4 days - 4.4 years). The most common pathogens were S. aureus (23%), Pseudomonas (19%), and coagulase negative staphylococci (13%). Overall median duration from onset of LVADI to exchange was 270 days (range, 4 days - 2.4 years). The median time from onset of LVADI to exchange was shorter in patients with no recurrence of LVADI compared to patients with recurrence (140 vs. 348 days). At one-year post-exchange; ten (32%) patients had recurrence with the same pathogen after a median duration of 25 days, 6 (19%) with a new pathogen after a median duration of 90 days, and 12 (39%) were infection free. The 30-day mortality was 3 (10%) patients. Overall, 16 (51%) patients had recurrent or new LVADI at 1 year and 19 (62%) at 2 years post-exchange. Survival at 1 and 2 years was 52% and 36% and cause of death in most patients was HCVA at 42% and 50%, respectively. Conclusion For patients receiving a pump exchange with a LVADI, this study suggests a lower incidence of recurrent LVADI with earlier device exchange. While device exchange should remain a consideration for difficult LVADI, it is associated with significant risk of morbidity and mortality at 1 and 2 years. Additional studies are needed to better define management strategies in patients undergoing a device exchange for the control of infection.

Increased Risk of Stroke and Death in Ventricular Assist Device Patients Varies by ISHLT Infection Category: An INTERMACS Analysis

Purpose Ventricular assist device (VAD) patients experience infections, which increase the risk of stroke and mortality. We aimed to characterize key differences in clinical outcomes for VAD patients based on the ISHLT categorization of infections: VAD-specific (e.g. pump component related), VAD-related (e.g. bloodstream infection, BSI) and non-VAD infections (e.g. pneumonia). Methods Query of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) identified 16,597 continuous-flow VAD recipients. Categories of infection were tested in multivariate models to determine the risk of stroke and death. Results After implant, 7,046 patients (42%) developed an infection at a median of 69 days (IQR: 12-272). A majority were non-VAD infections (49%) followed by VAD-related (26%) and VAD-specific infections (25%). Non-VAD and VAD-related infections had an incidence of 0.83 events/patient-year (EPPY) compared to 0.64 EPPY for VAD-specific infections (p Conclusion The ISHLT categorization of VAD infections unveils notable differences in associated risk of stroke and mortality. A re-assessment of transplant prioritization for eligible infected VAD patients may be useful to increase transplant related survival benefit.

Epidemiology, Outcomes, and Effects of Device Flow Type on Ventricular Assist Devices (VAD) Infections: An IMACS Registry Analysis

Purpose Infection remains an important cause of morbidity and mortality in continuous flow ventricular assist device (CF-VAD) recipients. It is unclear if flow type (axial or centrifugal) is associated with VAD infection and post-infection outcomes. This study aimed to investigate the device flow-type-specific rates of VAD infection and subsequent outcomes. Methods We analyzed IMACS adult patients with CF-LVADs from 2013-2017. We defined VAD infection using the ISHLT definitions as both VAD-specific infections including driveline, pump pocket/interior/exit cannula infection, and VAD-related infections including mediastinitis and VAD-related bloodstream infection. We compared the rates of VAD infections and post-infection events by flow type. Results Patients with axial devices (N=9988) had both higher early ( 3 months) rates (per 100 patient-months) of developing VAD infections compared to those with centrifugal (N=5572; Early: 2.3 vs. 1.8, p Conclusion VAD infection rates were higher in axial devices both in the early and late time periods following device implant; younger patients had a higher hazard of VAD infection in this group. VAD infection was associated with higher bleeding and mortality in both flow type groups. Infection prevention programs specifically targeting VAD infections should be a key component of VAD research.

Stroke and death risk in ventricular assist device patients varies by ISHLT infection category: An INTERMACS analysis.

Ventricular assist device (VAD) patients often experience infections, which increase the risk of stroke and mortality. Using the definitions of the International Society for Heart and Lung Transplantation (ISHLT), we have characterized differences in clinical outcomes for categories of infection: VAD-specific (e.g., pump component related); VAD-related (e.g., bloodstream infection, BSI); and non-VAD infections (e.g., pneumonia). Querying of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) identified 16,597 continuous-flow VAD recipients. Categories of infection were tested in multivariate models to determine the risk of stroke and death. After implant, 7,046 patients (42%) developed an infection at a median of 69 (interquartile range 12 to 272) days. A majority were non-VAD infections (49%), followed by VAD-related (26%) and VAD-specific infections (25%). BSIs were the most common form of VAD-related infection (92%), and the majority (59%) had no associated infection, that is, idiopathic bacteremia. Internal pump component infections were rare (0.003 event per patient-year [EPPY]). Infected VAD patients had a higher prevalence of stroke compared to patients without an infection (18% vs 11%, p < 0.001). The lowest stroke rate occurred after a VAD-specific infection (0.11 EPPY) compared with VAD-related (0.17 EPPY) and non-VAD infections (0.15 EPPY, p < 0.001). Hemorrhagic strokes were more common than ischemic strokes in all infection groups and highest after a VAD-related infection (0.13 EPPY). One-year survival after an infection was 87% in VAD-specific infections, as compared with VAD-related (71%) and non-VAD infections (72%, p < 0.001). The ISHLT categorization of VAD infections unveils notable differences in associated risk of stroke and mortality. A re-assessment of transplant prioritization for eligible infected VAD patients may be useful to increase transplant-related survival benefit.

Infections in patients using ventricular-assist devices: Comparison of the diagnostic performance of 18F-FDG PET/CT scan and leucocyte-labeled scintigraphy

BackgroundThe usage of left-ventricular-assist device (LVAD) is increasing in patients presenting with advanced heart failure. However, device-related infections are a challenge to recognize and to treat, with an important morbidity and mortality rate. The role of nuclear medicine imaging remains not well established for LVAD infections. The present study compared the accuracy of positron emission tomography/computed tomography with 18F-fludeoxyglucose (18F-FDG PET/CT) and radiolabeled leucocyte scintigraphy for the diagnosis of infections in patients supported with a continuous-flow LVAD. MethodsFrom a prospectively maintained database, we retrospectively analyzed the diagnostic performance of radiolabeled leucocyte scintigraphy and 18F-FDG PET/CT in 24 patients who had a LVAD with a suspected device-related infection. Both examinations were routinely performed in all patients. Infection was assessed by the International Society for Heart and Lung Transplantation criteria. ResultsTwenty-four patients were included: 15 had a specific VAD infection (5 cardiac-LVAD and 10 driveline), 6 had a VAD-related infection, while 3 patients had a non-VAD-related infection. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 95.2%, 66.7%, 95.2%, 66.7%, and 91.6%, respectively, for 18F-FDG-PET; and 71.4%, 100%, 100%, 33.3%, and 75%, respectively, for leucocyte scintigraphy. 18F-FDG PET/CT showed significantly higher sensitivity (P = 0.01) than leucocyte scintigraphy. Conclusion18F-FDG PET/CT and radiolabeled leucocyte scintigraphy single-photon emission computed tomography carry high performance in the diagnostic of LVAD infections. 18F-FDG PET/CT shows significantly higher sensitivity and could be proposed as first-line nuclear medicine procedure.