Cardiovascular Implantable Electronic Device Infections in Left Ventricular Assist Device Recipients

Abstract

Background Most patients with left ventricular assist devices (LVAD) have concomitant cardiovascular implantable electronic devices (CIED). However, clinical presentation and outcome of CIED infection in the setting of LVAD has not been previously described. Methods We retrospectively reviewed 247 patients who underwent LVAD implantation at Mayo Clinic campuses in Minnesota, Arizona and Florida, from January 2005 to December 2011. Demographic and clinical data of patients that met criteria for CIED infection were extracted. Results Of 247 patients with LVADs, 215 (87%) had CIED at the time of LVAD implantation and six (2.8%) subsequently developed CIED infections. Three patients developed CIED lead-related endocarditis and other 3 had pocket infection. All 3 instances of CIED pocket infection were preceded by device generator exchange, while all three patients with CIED lead-related endocarditis had prior LVAD-related infections. Causative pathogens included Pseudomonas aeruginosa (1), coagulase-negative staphylococci (2), methicillin-resistant Staphylococcus aureus (1), a gram-positive bacillus (1), and culture-negative (2). All patients underwent complete CIED removal along with antimicrobial therapy. The 3 patients with CIED lead- related endocarditis and prior LVAD infections received chronic suppressive antibiotic therapy, and one patient had LVAD exchange. All but one remained alive at the last follow-up with a median duration of 15 months (7–46 months) from the time of CIED infection. Conclusion Patients who are receiving LVAD therapy and develop CIED infection should be managed with complete CIED removal. Chronic suppressive antibiotic therapy is warranted in cases that have concomitant LVAD infection.

Cardiac Resynchronization Therapy and Clinical Outcomes in Continuous Flow Left Ventricular Assist Device Recipients

“…Based on our results, it appears reasonable to turn off the LV lead in CRT‐D patients following CF‐LVAD implant to save battery life and limit frequent pulse generator replacements. This is especially important given the higher risk of infection30 and periprocedural bleeding associated with procedures in the CF‐LVAD population.…”

Endocarditis in left ventricular assist device

“…The endovascular surface of LVAD must be presumed seeded in cases of implant device infection complicated by endocarditis. These cases should be managed with chronic suppressive antibiotic therapy until the infected LVAD is removed and replaced with a new device or until the patient undergoes cardiac transplantation (22). Conservative management of endocarditis without lead removal is reported as an ineffective treatment approach.…”

“…Currently, there is no data regarding specific approaches in the management of LVAD endocarditis, device exchange or explantation is generally based on the patient's overall clinical status. In our review, out of the 8 patients reported with bacterial endocarditis among all the studies, all of them received a prolonged course of antibiotics, 2 patients had explantation of the device and one patient had an exchange of the inflow and outflow valves (2,(22)(23)(24)(25)(26). Aggressive management of infection, with prompt device removal and prolonged antibiotic therapy targeting the specific organism, is crucial to prevent catastrophic events (1).…”

“…All patients underwent removal of the LVAD and were treated with a prolonged course of antibiotics. Only one patient survived (22). In another retrospective review done in the Netherlands, which included 38 patients who received LVAD between 1993 to 2001, …”

Implantable Cardioverter-defibrillator Therapy in the Patient with a Left Ventricular Assist Device: Still a Black Box

“…One common theme among previously published studies is that the best predictor of appropriate ICD therapy after an LVAD is implanted is the presence of sustained VAs prior to implantation (ie, secondary prevention population). 24 Other questions that must be considered include the potential for and the management of infection in the setting of concomitant LVAD and cardiovascular implantable electronic device implantation, 25 and the safety and efficacy of LVAD implantation done in conjunction with that of newer technologies, such as subcutaneous ICDs. 26 The efficacy and benefits of cardiac resynchronization therapy device use in LVAD recipients also remains a topic of interest.…”