Review
Ventricular assist device-related infections

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Summary

Heart failure is a leading cause of death in developed nations despite medical management. Cardiac transplantation is a potentially lifesaving intervention for approximately 4000 advanced heart failure patients per year; however, the demand for donor hearts far exceeds the supply. Ventricular assist devices provide temporary support for patients with severe heart failure until myocardial recovery occurs or a donor heart becomes available. For those ineligible for transplantation, ventricular assist devices may be used permanently and have demonstrated reduced mortality and an improved quality of life compared with continued medical therapy. Nonetheless, these devices are under-used, in part due to the frequency of complications. Device-related infections are one of the most frequent sequelae of ventricular assist device placement and occur in 18–59% of cases. Infections can involve any part of the device and confer substantial morbidity and mortality. Here, we provide an introduction to ventricular assist devices, explore the nature and pathogenesis of ventricular assist device-related infections, discuss problems with diagnosis, and present treatment and prevention strategies.

Section snippets

Heart failure

Heart failure occurs in 6–10% of individuals over the age of 65 years in developed nations,1 and over 2 million patients worldwide have end-stage disease.2 The prevalence of heart failure in Europe is 0·3–2%,3 and it affects approximately 10 million people living in nations represented by the European Society of Cardiology.4 According to the most recent American Heart Association statistics, 5 million Americans have congestive heart failure, with 550 000 new cases annually. In 2003, there were

Ventricular assist devices

Ventricular assist devices were developed to improve circulation in patients with advanced congestive heart failure. These devices function as mechanical pumps for damaged ventricles to maintain adequate blood flow. They may also lead to an improvement in myocardial contractility6, 7 and reverse remodelling, as evidenced by reduction of fibrosis and hypertrophy,8 and reversal of chamber enlargement while on ventricular support.9 There are three indications for mechanical assistance: bridge to

Ventricular assist device-related infections and their complications

Ventricular assist device-related infections occur in 18–59% of patients after ventricular assist device implantation.17, 18, 19, 20, 21, 22, 23 In a literature review by Baddour and colleagues,29 infections have been reported to occur in 13–80% of cases. The true incidence of ventricular assist device-related infections is difficult to ascertain for several reasons, including lack of a universal definition of device-related infection, use of historical data, different interpretations of

Pathogenesis

To date, there has been limited investigation of the pathogenesis of ventricular assist device-related infections. This complex process likely involves a combination of ventricular assist device-related, surgical, host, and bacterial factors.

Most ventricular assist devices are large devices and are susceptible to infections at numerous sites, including the internal components of the device (eg, pump membrane and inflow and outflow tracts), the pump pocket, and the driveline exit site. These

Diagnosis and presentation

Although infection is a common complication of ventricular assist device use, there are few documented, prospective, detailed comparisons of clinical signs and symptoms between infected and non-infected individuals. Ventricular assist device-related infections may be associated with few signs and symptoms or may be difficult or impossible to differentiate from infections at other sites. Positive cultures, representing contamination or colonisation, may be incorrectly interpreted as representing

Treatment

Empiric treatment of ventricular assist device-related infections is dependent on the suspected site(s) of infection and the degree of illness. Often, empiric therapy is instituted early because of patients' multiple medical problems. While blood cultures and a full diagnostic work-up are pending (when possible, cultures should be obtained before initiation of antibiotics), empiric treatment of sepsis includes broad-spectrum antibiotics, including Gram-positive (eg, vancomycin for possible

Prevention

Numerous strategies have been used to prevent ventricular assist device-related infections. Without any clinical trial data, the efficacy of these strategies is difficult to gauge based on clinical experience alone.68

Future studies

In the future, a set of criteria to diagnose ventricular assist device-related infections should be generated and validated. Universal criteria will help determine the incidence of ventricular assist device-related infections and allow comparisons of infection rates among different centres, device types, surgical techniques, and prevention strategies. New prevention and treatment strategies, such as those discussed above, should be rigorously investigated. Other prevention strategies—eg, an

Search strategy and selection criteria

Data for this review were identified by searches of PubMed, Medline, and references from relevant articles; numerous articles were identified through searches of the extensive files of the authors. Search terms included “ventricular assist device”, “heart-assist devices”, “VAD”, and “LVAD”. They were cross-referenced with search terms including “infection”, “staphylococcus”, “Gram-positive”, “Gram-negative”, fungi”, and “cost(s)”. Several studies presented overlapping data sets, including

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