24 Managing infections associated with LVADs

Although left ventricular assist devices (LVADs) have revolutionised the treatment of advanced heart failure, LVAD infection (LVADI) remains a significant cause of morbidity and mortality in LVAD patients. The International Society of Heart and Lung Transplantation defines LVADI in three categories: VAD-specific infections (pump/cannula, pocket, driveline); VAD-related infections (infective endocarditis, blood stream infection, mediastinitis); and non-VAD infections.1 Infection should be excluded or appropriately treated by an infectious disease physician before LVAD implantation when clinically feasible. Surgical techniques such as increasing intrafascial tunnelling and externalisation of the silicone portion of the driveline may help reduce infections.2 Besides culture tests, additional imaging, such as ultrasonography or computed tomography may be warranted if underlying abscess is suspected.3 The recommended treatment includes antimicrobial therapy, local debridement of the exit sites; surgical drainage, driveline repositioning and instalment of a wound VAC (or vacuum-assisted closure) system in patients with deep infection,4 surgical debridement and device exchange in the setting of persistent or relapsing blood stream infection (BSI) despite adequate antimicrobial and surgical therapy; pump exchange should be performed if feasible, in patients with persistent sepsis and instability due to device infection while heart transplant should be considered in haemodynamically stable transplant candidates with BSI.1 The clinical manifestations and management of LVADI vary based on the type and extent of infection, and the causative pathogens. Understanding these differences is critical in making timely diagnoses and providing appropriate management interventions for LVADI. References Kusne S, Mooney M, Danziger-Isakov L, Kaan A, Lund LH, Lyster H, Wieselthaler G, Aslam S, Cagliostro B, Chen J, Combs P, Cochrane A, Conway J, Cowger J, Frigerio M, Gellatly R, Grossi P, Gustafsson F, Hannan M, Lorts A, Martin S, Pinney S, Silveira FP, Schubert S, Schueler S, Strueber M, Uriel N, Wrightson N, Zabner R, Huprikar S. An ISHLT consensus document for prevention and management strategies for mechanical circulatory support infection. J Heart Lung Transplant 2017;36:1137–1153. Trachtenberg BH, Cordero-Reyes A, Elias B, Loebe M. A review of infections in patients with left ventricular assist devices: prevention, diagnosis and management. Methodist Debakey Cardiovasc J 2015;11:28–32. Slaughter MS, Pagani FD, Rogers JG, Miller LW, Sun B, Russell SD, Starling RC, Chen L, Boyle AJ, Chillcott S, Adamson RM, Blood MS, Camacho MT, Idrissi KA, Petty M, Sobieski M, Wright S, Myers TJ, Farrar DJ; HeartMate II Clinical Investigators. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 2010;29(4 Suppl):S1–39. Yarboro LT, Bergin JD, Kennedy JL, Ballew CC, Benton EM, Ailawadi G, Kern JA. Technique for minimizing and treating driveline infections. Ann Cardiothorac Surg 2014;3:557–562.