The LVAD patients ≥ 70 years of age have good functional recovery, survival, and quality of life at 2 years. Advanced age should not be used as an independent contraindication when selecting a patient for LVAD therapy at experienced centers.
Percutaneous driveline lead and pocket sites are potential sources of drainage that can lead to infection. Some patients experience a slower closure of tissue growth into the driveline. The management of chronically open and or draining driveline wounds is a challenge. The KCI vacuum-assisted closure (VAC) device is a noninvasive negative-pressure therapy that promotes the healing of wounds not responding to conventional treatment. Vacuum-assisted closure therapy has proven safe, effective, and cost efficient by decreasing the number of dressing changes and length of stay. The left ventricular assist device (LVAD) team initiated VAC therapy in 3 patients. The tunneling method allowed the wound to heal from the inside out. The dressing was changed every 3 days, and the size and depth of the wound was monitored. Patients may be sent home using a portable VAC device until wound closure is obtained, which decreases the hospital length of stay. Our experience with three patients suggests the VAC device can be used for draining and tunneling LVAD driveline-site wounds and may prevent fistula formation. It is especially useful for patients with ascites that may be draining along the driveline tract. The sites showed increased granulation, decreased drainage, and a reduced bacterial burden after having the device in place.
Favorable long-term patient outcome after insertion of a left ventricular assist device (LVAD) as a bridge to recovery or destination therapy for the treatment of end-stage cardiomyopathy is adversely affected by pathophysiologic changes affecting the heart. Alterations in the native aortic valve apparatus, specifically aortic valve cusp fusion, is an example of such a phenomenon and may especially affect patients in cases of bridge to recovery, a rare but reported event. A retrospective review of the last 33 LVAD placements at our institution was conducted, including reviews of operative reports and pathologic examinations of the native hearts. Seven hearts were found to have varying degrees of aortic valve cusp fusion after chronic LVAD support (63-1, 339 days). Five of these patients had native aortic valves, and two had bioprosthetic valves. The left ventricular outflow tracts in two patients were surgically occluded at the time of LVAD insertion. Aortic valve cusp fusion occurs in roughly 25% of patients on chronic LVAD support. This phenomenon may prove to be clinically significant by creating a potential source of emboli and infection. In addition, in the case of myocardial recovery, left ventricular outflow tract obstruction could limit parallel flow and produce suprasystemic ventricular pressures that in turn would elevate left ventricular end diastolic pressures. The latter may contribute to further myocardial injury, ultimately limiting the ability of an otherwise recovered heart to be weaned from LVAD support.
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