Left ventricular assist device-associated infections: incidence and risk factors.

BACKGROUND: Left ventricular assist device (LVAD)-associated infections are major complications that can lead to critical outcomes. The aims of this study were to assess the incidence of and to determine the risk factors for LVAD-associated infections. METHODS: We included all consecutive patients undergoing LVAD implantation between January 1, 2010, and January 1, 2019, in a single institution. Infection-related data were retrospectively collected by review of patient's medical files. LVAD-associated infections were classified into three categories: percutaneous driveline infections, pocket infections and pump and/or cannula infections. RESULTS: We enrolled 72 patients. Twenty-one (29.2%) patients presented a total of 32 LVAD-associated infections. Eight (38.1%) patients had more than one infection. Five (62.5%) pocket infections and one (50.0%) pump and/or cannula infection were preceded by a driveline infection. The median delay between the operation and LVAD-associated infection was 6.5 (1.4-12.4) months. The probability of having a LVAD-associated infection at one year after receiving an implant was 26.6% (95% CI: 17.5-40.5%). Percutaneous driveline infections represented 68.7% of all LVAD-associated infections. Staphylococcus aureus and coagulase-negative staphylococci were the predominant bacteria in LVAD-associated infections (53.1% and 15.6%, respectively). Hospital length of stay (sdHR =1.22 per 10 days; P=0.001) and postoperative hemodialysis (sdHR =0.17; P=0.004) were statistically associated with infection. Colonization with multidrug-resistant bacteria was more frequent in patients with LVAD-associated infections than in others patients (42.9% vs. 15.7%; P=0.013). CONCLUSIONS: LVAD-associated infections remain an important complication and are mostly represented by percutaneous driveline infections. Gram-positive cocci are the main pathogens isolated in microbiological samples. Patients with LVAD-associated infections are more frequently colonized with multidrug-resistant bacteria.

Decompressive hemicraniectomy for acute ischemic stroke in a patient implanted with a left ventricular assist device: a case report.

BACKGROUND: Thromboembolic ischemic stroke (IS) is one of the most feared complications of left ventricular assist device (LVAD) placement and represents a challenge to surgical management because of concomitant anticoagulant therapy. CASE PRESENTATION: A 39-year-old man presented with cardiogenic shock following an out-of-hospital cardiac arrest. After a period of stabilization, the patient was referred for LVAD placement. Upon recovery from anesthesia, he presented with acute neurological deficits suggestive of IS. A brain computed tomography confirmed the diagnosis, and an emergency decompressive hemicraniectomy (DHC) was performed. Anticoagulation was managed empirically. The patient's neurological status progressively improved and he was referred for heart transplantation at five months from DHC. One month later, cranioplasty was performed. CONCLUSIONS: This report suggests an anticoagulation management approach in combination with decompressive craniectomy after IS in a patient with LVAD placement was successful. An optimized anticoagulation management and collaborative team-based practice may contribute to successful outcomes in complex cases.

Minimally invasive surgery for left ventricular assist device implantation is safe and associated with a decreased risk of right ventricular failure.

BACKGROUND: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is associated with significant mortality and morbidity. The objective of this study was to determine pre- and postoperative risk factors associated with the occurrence of RVF after LVAD implantation. METHODS: This retrospective study included 68 patients who received LVADs between 2010 and 2018 either for bridge to transplant (40 patients, 58.8%) or bridge to destination therapy (28 patients, 41.2%). RVF after LVAD implantation was defined according to the INTERMACS classification. The primary endpoint was the occurrence of RVF. The secondary endpoints were hospital mortality and morbidity and long-term survival. RESULTS: The majority of patients (61.8%) had an INTERMACS profile 1 (36.8%) or 2 (25.0%). The LVAD was implanted either by sternotomy (37 patients, 54.4%) or thoracotomy (31 patients, 45.6%). RVF after LVAD implantation was observed in 32 patients (47.1%). In univariate analysis, an elevated serum glutamic oxaloacetic transaminase (SGOT) (P=0.028) and a high preoperative vasoactive inotropic score (VIS) (P=0.028) were significantly associated with an increased risk of RVF, whereas the implantation of LVAD through a thoracotomy approach was associated with a significant reduction in this risk (P=0.006). The multivariate analysis demonstrated that only the thoracotomy approach was significantly associated with decreased risk of RVF (odds ratio =0.33, 95% confidence interval: 0.17-0.96; P=0.042). Hospital mortality was 53.1% and 5.6% in the RVF and control groups, respectively (P<0.0001). The incidence of stroke and postoperative acute renal failure were significantly increased in the RVF group compared with the control group. The survival after LVAD implantation was 33.5%±9.0% and 85.4%±6.0% at 1 year in the RVF and control groups, respectively (P<0.0001). CONCLUSIONS: LVAD implantation by thoracotomy significantly reduced the risk of postoperative RVF. This surgical approach should, therefore, be favored.

In Trauma Patients, the Occurrence of Early-Onset Nosocomial Infections is Associated With Increased Plasma Concentrations of Chromogranin A.

In previously healthy persons suffering from acute illnesses, nosocomial infections (NIs) are frequent. Their prevalence suggests the existence of as yet unknown conditions that may promote care-related infection. This study assessed whether the measurement of plasma chromogranin A, a stress-related protein involved in innate defense, is related to NI risk, and whether any chromogranin A-derived fragment included in vasostatin-I displays immunosuppressive activities related to AP-1 or NF-kappa B downregulation. At the clinical level, trauma patients and healthy controls were recruited to be eligible. Clinical histories were recorded, and standard biological tests (including plasma chromogranin A) were performed. For 9 randomly chosen patients and 16 controls, the time-dependent concentrations of chromogranin A (CGA) were assessed twice a day over 66 h. The data show that trauma patients present a higher value of CGA concentration during 66 h in comparison with healthy controls. In addition, patients maintaining this significant increase in CGA readily develop NIs. We therefore studied the effects of chromogranin A-derived peptides on monocytes, focusing on transcription factors that play a central role in inflammation. In vitro assay demonstrated that a chromogranin A-derived fragment (CGA47-70) displays a significant inhibition of NF-kappa B and AP-1 transcriptional activities in these cells. In conclusion, the occurrence of NI in trauma patients is associated with significantly increased plasma CGA concentrations. Downregulation of the two transcription factors by CGA47-70 might induce early acquired immune defect after a serious medical stress.

Impact of prosthesis-patient mismatch on early haemodynamic status after aortic valve replacement.

OBJECTIVES: Prosthesis-patient mismatch (PPM) has been reported to impact early haemodynamic status and early mortality after prosthetic aortic valve replacement (AVR) in patients with aortic stenosis (AS). The aim of this study was to assess the impact of PMM on early haemodynamic status after AVR using vasoactive-inotropic dependency index (VDI), postoperative pressures and end-organ perfusion. METHODS: A total of 183 patients with AS were included in this prospective cohort study, and underwent elective AVR with or without combined coronary artery bypass graft surgery. PPM was defined as a projected indexed effective orifice area of ≤0.85 cm2/m2, and was present in 27.9% of the patients. The primary end-point was the VDI [VDI = vasoactive-inotropic score/mean arterial pressure] measured upon admission to the intensive care unit (POD0) and on the morning of the first postoperative day (POD1). The secondary end-points were the following: mean left atrial pressure, mean central venous pressure, fluid balance, brain natriuretic peptide, troponin I, glomerular filtration rate and lactate levels on POD0 and POD1. RESULTS: No significant differences in VDI were observed between the no PPM and PPM groups on POD0 (0.08 ± 0.48 vs 0.05 ± 0.13, respectively, P = 0.622) or on POD1 (0.09 ± 0.40 vs 0.06 ± 0.13, respectively; P = 0.583). The mean arterial pressure, mean left atrial pressure, central venous pressure, troponin I, glomerular filtration rate and lactate levels did not differ between the two groups on POD0 and POD1, as well as fluid balance and brain natriuretic peptide on POD1. CONCLUSIONS: PPM is not associated with early haemodynamic status impairment and end-organ perfusion after AVR. CLINICAL TRIAL NUMBER: ClinicalTrials.gov number, NCT00699673.