*Purpose: Infection involving Left Ventricular Assist Device (LVAD) in patients who receive device therapy as a bridge to heart transplantation (HT) is a serious complication. If inadequately treated, these infections may lead to significant post-transplant morbidity. However, there is insufficient data regarding post HT management of patients who are on suppressive antimicrobial therapy for LVAD infection (LVADI) at the time of HT. We aimed to describe the treatment strategies and outcomes of patients undergoing HT with preceding LVADI.

*Methods: We retrospectively reviewed all adults who underwent HT at our institution from 2010 through 2018 and had LVAD implanted as bridge to HT. Cases of LVADI prior to HT were classified using International Society for Heart and Lung Transplantation (ISHLT) definitions. Outcomes including infection relapse and survival were analyzed.

*Results: A total of 39 patients met study criteria. Of these, 13 (33.3%) were classified as cases of LVADI. LVAD-specific infections accounted for 9/13 (69.2%) of cases, the majority of which involved the driveline/pocket and pump sites simultaneously (7/9, 77%). The remaining 4/13 (30.7%) cases were categorized as LVAD-related bloodstream infections (BSI). Pre-HT, all patients were on chronic antimicrobial suppression. Median duration of therapy was 217 days (IQR 104-367.5). No patients were deemed septic at the time of HT and all had negative blood cultures on pathogen-directed therapy. Intra-operative cultures were obtained in 7/9 (77.7%) patients with LVAD-specific infections and in none of the LVAD-related BSI cases. Operative findings consistent with infection were reported in 7/13 patients (53.8%), all cases of LVAD-driveline and pocket infection. Following HT and debridement, pathogen-directed therapy was continued in 7/9 (77.7%) proven LVAD-specific infections per ISHLT criteria, for a median duration of 21 days (IQR 14-28). Three of these cases (3/7, 42.8%), required additional surgical debridement during the same hospital stay. Of note, none of the patients with LVAD-related infections (4/4) received post-transplant antimicrobial therapy to treat for pre-transplant LVADI. All patients were alive at 1-year follow up and none experienced infection relapse following hospital discharge.

*Conclusions: In this cohort, patients who met ISHTL criteria for proven LVAD-specific infection at the time of HT, received 2 to 3 weeks of pathogen-directed therapy post-HT. In contrast, in those without proven infection, antimicrobial therapy was not extended. Similarly, in cases of pre-transplant LVAD-related BSI who completed therapy for BSI and achieved negative blood cultures, extension of therapy after HT was not indicated. Using this management approach, no patients experienced infection relapse or decreased survival. Larger-scale studies with comparator groups are needed.

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