LVAD bloodstream infections: therapeutic rationale for transplantation after LVAD infection.

INTRODUCTION Patients who have ventricular assist devices (VADs) and experience bloodstream infection (BSI) have high mortality. We addressed 2 questions raised by the United Network for Organ Sharing (UNOS) priority policy for this problem: 1) Are organs wasted on this ultra-high-risk group? 2) Can device-related BSI be differentiated from transient BSI? METHODS Patients with VADs who underwent heart transplantation from 1987 to 2001, who had BSI during VAD support, and who had positive cultures at VAD explant (device-related BSI, n = 10) were compared with those with negative cultures at explant (non-device-related BSI, n = 11). RESULTS Patients with device-related BSI had an 80% (8/10) rate of persistent bacteremia; 30 days and 1 year after transplantation, mortality was 14% and 26%, respectively. Non-device-related BSI (n = 11) persisted in 18% (2/11); peri-operative and 1-year mortalities were 9% and 13%. Duration of VAD support predicted infection (132 vs 48 days, p < 0.001); hypo-albuminemia (2.9 +/- 0.5 mg/dl vs 3.3 +/- 0.8 mg/dl, p < 0.05), and a resistant organism predicted a device-related BSI. These patients had increased intubation requirements and had increased creatinine concentration during the first post-operative week, with no difference in liver function, blood loss, transfusions (packed red blood cells, fresh frozen plasma, or platelets), or hemodynamic stability vs patients with non-device BSI. Despite decreased immunosuppression, we found no difference in acute rejection events with device-related BSI. Re-infection with the pre-operative organism occurred in only 1 patient per group. CONCLUSIONS These data suggest that urgent (Status 1A) cardiac transplantation is effective in stable patients with device-related BSI, and these data support the current UNOS policy. However, an extra-device source of BSI should be excluded by considering the isolated organism, the baseline nutritional status, and other risk factors.

[1]  W. Konertz,et al.  Diagnosis and management of left ventricular assist device valve-endocarditis: LVAD valve replacement. , 2000, The Annals of thoracic surgery.

[2]  H. Scheld,et al.  Left ventricular assist device infection is associated with increased mortality but is not a contraindication to transplantation. , 1997, Circulation.

[3]  G. Trenholme,et al.  Infectious complications in left ventricular assist device recipients. , 1997, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[4]  R. Bolman,et al.  Effects of left ventricular assist devices on outcomes in patients undergoing heart transplantation. , 2000, The Annals of thoracic surgery.

[5]  C. Yancy,et al.  Risk factors for early, cumulative, and fatal infections after heart transplantation: a multiinstitutional study. , 1996, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[6]  H Stammer,et al.  Nasal Carriage as a Source of Staphylococcus aureus Bacteremia , 2001 .

[7]  P. Glasziou,et al.  Bed rest: a potentially harmful treatment needing more careful evaluation , 1999, The Lancet.

[8]  R. Benza,et al.  Infection during circulatory support with ventricular assist devices. , 1999, The Annals of thoracic surgery.

[9]  M. Oz,et al.  Outpatient left ventricular assist device support: a destination rather than a bridge. , 1996, The Annals of thoracic surgery.

[10]  M. Oz,et al.  The influence of infection on survival and successful transplantation in patients with left ventricular assist devices. , 1997, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[11]  M. Oz,et al.  Early progressive mobilization of patients with left ventricular assist devices is safe and optimizes recovery before heart transplantation. , 1996, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[12]  M. Oz,et al.  Fungal left ventricular assist device endocarditis. , 2001, The Annals of thoracic surgery.

[13]  P. McCarthy,et al.  Nosocomial bloodstream infections in patients with implantable left ventricular assist devices. , 2001, The Annals of thoracic surgery.

[14]  G. Couper,et al.  Salvage of externally exposed ventricular assist devices. , 1998, Plastic and reconstructive surgery.

[15]  V. Walley,et al.  Cardiac transplantation after mechanical circulatory support: a Canadian perspective. , 1996, The Annals of thoracic surgery.

[16]  M Schetz,et al.  Intensive insulin therapy in critically ill patients. , 2001, The New England journal of medicine.

[17]  P. McCarthy,et al.  Implantable LVAD infections: implications for permanent use of the device. , 1996, The Annals of thoracic surgery.

[18]  S. Heisterkamp,et al.  Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebo-controlled trial , 2001, The Lancet.

[19]  T. Myers,et al.  Infectious complications associated with ventricular assist systems. , 2000, ASAIO journal.

[20]  Homologous blood transfusion as a risk factor for postoperative infection after coronary artery bypass graft operations. , 1992 .

[21]  L. Harrison,et al.  Relapsing bacteremia in patients with ventricular assist device: an emergent complication of extended circulatory support. , 2001, The Annals of thoracic surgery.

[22]  M C Oz,et al.  Long-term use of a left ventricular assist device for end-stage heart failure. , 2001, The New England journal of medicine.

[23]  M. Oz,et al.  Infections During Left Ventricular Assist Device Support Do Not Affect Posttransplant Outcomes , 2000, Circulation.

[24]  J. Long,et al.  Treatment of infected left ventricular assist device using antibiotic-impregnated beads. , 1999, The Annals of thoracic surgery.

[25]  O. Akca,et al.  Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. , 2000, The New England journal of medicine.

[26]  E. Lefrak,et al.  Surgical complications in bridging to transplantation: the Thermo Cardiosystems LVAD. , 1992, The Annals of thoracic surgery.

[27]  M. Léon-Sanz.  Perioperative total parenteral nutrition in surgical patients. , 1992, The New England journal of medicine.