Surgical infection prophylaxis for left ventricular assist device implantation

Abstract Background: Antimicrobial prophylaxis is commonly administered to patients undergoing left ventricular assist device (LVAD) surgeries to prevent infectious complications. However, optimal surgical infection prophylaxis (SIP) for LVAD surgeries is not well defined. Methods: We conducted an electronic survey to characterize LVAD SIP used at different centers performing LVAD implantation. Results: Responses were received from 23 of 85 centers (27%). Of 21 centers that provided usable data about their LVAD SIP regimens for nonpenicillin allergic patients, 42.9% reported using a four‐drug regimen (three antibiotics plus fluconazole), 23.8% reported using a three‐drug regimen (three antibiotics or two antibiotics plus fluconazole), 23.8% reported using a regimen of two antibiotics, and 9.5% reported using vancomycin alone. A similar pattern was observed among SIP regimens for penicillin‐allergic patients. Criteria for discontinuation of SIP and use of decolonization strategies also varied widely across centers. Conclusions: Our results demonstrate wide variability in LVAD SIP regimens and underscore the lack of consensus regarding best practice. (J Card Surg 2011;26:440‐443)     

Wound complications after left ventricular assist device implantation

BACKGROUND: Wound necrosis and infection pose a tremendous risk for patients with left ventricular assist devices. METHODS: We analyzed our database of patients with left ventricular assist devices for those who developed wound dehiscence and concomitant infection after left ventricular assist device implantation. RESULTS: Three of our 66 patients (4.5%) with implantable ventricular assist devices had had severe wound complications with necrosis of the abdominal or thoracic wall uncovering part of the device. The predominant impact on the development of these complications was presumably related to multiple surgical interventions on the same site. CONCLUSIONS: Nevertheless, these patients can recover and undergo successful heart transplantation if adequately managed.     

Plasma exchange before surgery for left ventricular assist device implantation

Abstract:  Left ventricular assist device (LVAD) implantation in end-stage heart failure patients is frequently associated with hemorrhagic complications requiring reoperation. The preoperative coagulopathic profile includes prolonged prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time; platelet dysfunction; decreased coagulation factor activity; and increased inflammatory markers. We compare outcomes in LVAD patients treated with preoperative plasma exchange with concurrent, nonrandomized control patients. We reviewed data from 68 consecutive elective patients who received LVADs at our institution. Thirty-five received LVADs after preoperative plasma exchange (replacement of one plasma volume of fresh frozen plasma), and 33 received LVADs without plasma exchange. Groups were comparable in age, sex, body weight, New York Heart Association class, intra-aortic balloon pump insertion, cardiac index, pulmonary capillary wedge pressure, creatinine, total bilirubin, hemoglobin levels, PT, international normalized ratio, PTT, and platelet count. Early mortality was lower in the plasma exchange group (0% [0/35] vs. 18% [6/33], P  = 0.026), and postoperative chest tube drainage decreased by 33% ( P  = not significant). Blood transfusion requirements were similar.Perioperative mortality decreased in patients treated with plasma exchange before LVAD implantation.     

Right ventricular failure after left ventricular assist device implantation: the need for an implantable right ventricular assist device

Right ventricular failure after implantation of a left ventricular assist device is an unremitting problem. Consideration of portal circulation is important for reversing liver dysfunction and preventing multiple organ failure after left ventricular assist device implantation. To achieve these objectives, it is imperative to maintain the central venous pressure as low as possible. A more positive application of right ventricular assistance is recommended. Implantable pulsatile left ventricular assist devices cannot be used as a right ventricular assist device because of their structure and device size. To improve future prospects, it is necessary to develop an implantable right ventricular assist device based on a rotary blood pump.     

Temporal changes in hospital costs for left ventricular assist device implantation

Abstract Background: A recent prospective, randomized controlled trial demonstrated that a continuous‐flow (CF) left ventricular assist device (LVAD) resulted in improved survival at 12 and 24 months compared to a pulsatile‐flow (PF) device. The current study examines the hospitalization costs associated with treatment of New York Heart Failure Class IV patients when implanted with a CF LVAD and compares them to previously reported costs of a PF LVAD in the same population. Methods: Hospital billing data were analyzed for CF LVAD patients in the HeartMate II Destination Therapy trial to determine costs associated with the implantation admission. Hospital charges were converted to costs using hospital specific cost‐to‐charge ratios. Hospital costs were evaluated based on patient outcomes and compared to previously reported results from patients who received a pulsatile flow LVAD in Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure. Multivariate models were created to determine the primary determinates of cost. Results: Hospital bills were available for 83 CF and 52 PF LVAD patients. Hospital length of stay and in‐hospital mortality were lower in the CF cohort. Inflation‐adjusted hospital costs were significantly lower for CF patients compared to PF patients (mean: $193,812 vs. $384,260, p < 0.001). Clinical factors that strongly influenced hospitalization costs included bleeding, respiratory failure, and infection. Conclusions: There has been a 50% reduction in the hospitalization cost associated with LVAD implantation since 2001. Improvements in operative technique and postoperative management appear to play critical roles in the observed cost reduction. (J Card Surg 2011;26:535‐541)     

Postoperative management of patients undergoing left ventricular assist device implantation

Left ventricular assist devices (LVAD) have become an important option for the treatment of patients with advanced heart failure. Unfortunately, patients undergoing LVAD-implantation still experience considerable perioperative morbidity and mortality. Right ventricular failure, bleeding, infections and device-associated problems represent the major postoperative complications. The present overview summarizes current strategies for preoperative risk estimation and for the prevention and treatment of frequently occurring perioperative complications.     

Rapid pacing for the off-pump insertion of the Jarvik left ventricular assist device

We present our technique for the implantation of the Jarvik 2000 left ventricular assist device (Jarvik Heart, Inc, New York, NY) without cardiopulmonary bypass by the induction of rapid pacing that allows the insertion of the apical device into the left ventricle, minimizing blood loss and surgical complications. Although the off-pump implantation of left ventricular assist devices is not new, our experience of rapid pacing has not been previously reported to our knowledge.     

Left thoracotomy approach for implantation of the Abiomed left ventricular assist device

We describe a left thoracotomy approach for implantation of the Abiomed AB5000 left ventricular assist device (LVAD). The technique is easily performed and spares the patient a sternotomy in anticipation of future transplantation or LVAD exchange.     

HeartWare left ventricular assist device implantation through bilateral anterior thoracotomy

The HeartWare left ventricular assist device (LVAD) is a new addition to the family of second-generation continuous-flow LVADs. The miniaturized dimensions of the HeartWare LVAD provide the opportunity for its safe implantation through nonsternotomy incisions. We present our technique for HeartWare LVAD implantation through bilateral anterior thoracotomy incisions. This technique has proved to be safe and reproducible, with good clinical outcome.     

Intraoperative transoesophageal echocardiography for implantation of a pulsatile left ventricular assist device

We describe the insertion of a permanent implantable left ventricular assist device and intraoperative transoesophageal echocardiography in this instance. We also review the literature on the use of intraoperative transoesophageal echocardiography.