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Bloodstream Infections in Continuous Flow Left Ventricular Assist Device Recipients

Diagnostic and Clinical Implications

Kyvernitakis, Andreas*; Pappas, Orestis*; Farmakiotis, Dimitrios; Horn, Edward T.; Benza, Raymond L.*; Bailey, Stephen H.§; Agarwal, Richa*

doi: 10.1097/MAT.0000000000000881
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Bloodstream infection (BSI) is a common complication of left ventricular assist device (LVAD) support and particularly difficult to treat. The presentation is often variable because of altered physiology and augmentation of cardiac output by the device. We studied LVAD recipients at a single institution. Multivariate logistic and Cox (with time-varying parameters) regression were implemented. Of 212 patients, 58% experienced infections. Driveline infection (DLI) affected 31%, with 60% of them having deep-tissue involvement. Sixty-six patients (31%) suffered from 135 BSIs. Systemic inflammatory response syndrome (SIRS) was present in 47% of BSIs at presentation and associated with increased mortality. Right heart failure, destination therapy, INTERMACS, morbid obesity, and deep-DLI were independent risk factors for BSI. The BSI was independently associated with mortality. Bridge-to-transplantation (BTT) patients were more likely to receive transplant if they did not have BSIs. Among 104 BTT patients who received heart transplantation, development of BSI was associated with shorter time-to-transplantation. Diagnosis of BSI poses diagnostic and prognostic challenges because of the hemodynamic profile of LVAD patients who may not mount the expected physiologic response to sepsis. Although SIRS criteria lack sensitivity in the LVAD population, SIRS signifies increased risk for death. Deep DLI was the strongest predictor of BSI. Despite the upgrade in listing status of BTT-LVADs with BSIs and shorter time-to-transplantation, BSI remain a major cause of mortality. BSIs are associated with significant mortality and should be regarded as a serious complication, similar to pump thrombosis and stroke.

From the Departments of *Cardiovascular Disease, Allegheny General Hospital, Pittsburgh, Philadelphia

Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Philadelphia

§Department of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, Philadelphia

Infectious Diseases, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Submitted for consideration March 2018; accepted for publication in revised form August 2018.

Disclosure: Dr. Farmakiotis has received research support from Astellas Phearma. The other authors have no conflicts of interest - report.

Correspondence: Richa Agarwal, Temple University School of Medicine, Division of Cardiovascular Medicine, Cardiovascular Institute, Allegheny Health Network, 320 East North Avenue, Allegheny General Hospital, Pittsburgh, PA 15212. Email: reech44@gmail.com.

Copyright © 2019 by the American Society for Artificial Internal Organs