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PURPOSE: Left ventricular assist devices (LVAD) greatly improve survival for patients with end-stage cardiac failure, but LVAD infections remain a significant challenge with predictive risk factors poorly understood. Furthermore, the indications and utility of escalating treatment from medical management to surgical debridement and flap reconstruction are not well-characterized. METHODS: A retrospective review of consecutive patients undergoing primary LVAD implantation at a tertiary academic center was performed. Primary outcomes were 90-day and overall mortality after LVAD infections. Cox proportional hazards regression was used to generate a risk-prediction score for mortality. RESULTS: Of the 760 patients undergoing primary LVAD implantation, 255 (34%) developed an LVAD infection of whom 91 (36%) were managed medically, 134 (52%) surgical debridement, and 30 (12%) with surgical debridement and flap reconstruction. One-year survival after infection was 85% with median survival of 2.40 years. Factors independently associating with mortality were diabetes (hazard ratio (HR) 1.44, p=0.04), MRSA infection (HR 1.64, p=0.03), deep space involvement (pump pocket/outflow cannula) (HR 2.26, p<0.001), ECMO after LVAD (HR 2.52, p<0.01), and MSSA infection (HR 0.63, p=0.03). A clinical risk-prediction score stratifying patients by mortality using these factors observed significant differences in median survival of 5.67 years for low-risk patients (score 0-1), 3.62 years for intermediate-risk (score 2), and 1.48 years for high-risk (score ≥3) (p<0.001). CONCLUSION: A clinical risk tool for identifying patients at high-risk of developing LVAD infection is presented, and differential management strategies are characterized. Surgeons may consider earlier surgical debridement and potential flap reconstruction to alter patient risk trajectory.
Chi et al. (Wed,) studied this question.