Brian A. Foley

Infection in ventricular assist devices: prevention and treatment

Infection is one of the most important challenges to the use of implanted mechanical circulatory support systems (MCSS), particularly as we enter the era of permanent device use in patients who are not candidates for cardiac transplantation. This paper describes the pathogenesis of MCSS infection, with particular attention to the role of biofilm-forming bacteria. Suggestions are presented for the prevention and treatment of infections in implanted MCSS.

Cardiomyopathy in a carrier of duchenne’s muscular dystrophy

During the third trimester of her pregnancy, a 25-year-old carrier of Duchennes muscular dystrophy developed severe cardiac failure and required mechanical circulatory support and transplantation. Her cardiac function improved during 311 days of circulatory support. However this improvement was not sufficient to allow removal of her left ventricular assist device before transplantation.

Neuropsychological functioning among heart transplant candidates : A case control study

Neuropsychological performance was examined among a group of patients with end-stage heart disease undergoing routine evaluation for transplantation using a matched case-control design. Heart transplant candidates and controls were matched case by case for gender, race, education and age range. In order to match all 44 controls, a clinical series of 303 heart transplant candidates evaluated between October 1995 through March 1998 were considered. Although not specifically matched on variables of estimated IQ and socioeconomic status, statistical analysis showed no group differences on these variables. A separate analysis of variance on each neuropsychological test indicated that the heart transplant candidates performed significantly worse than controls on tasks of fine motor speed and dexterity (i.e., Grooved Peg Board), psychomotor speed and mental flexibility (i.e., Trail Making Test,Part B), and reasoning and problem solving ability (i.e., Shipley Institute of Living Scale-Abstraction subtest). Implications of the results and future directions are discussed.

Treatment of end-stage heart disease with outpatient ventricular assist devices

BACKGROUND Initiating outpatient therapy with ventricular assist devices (VAD) was important in the progress of mechanical circulatory support. This article reviews our experience with VAD therapy from the start of our outpatient program until the present. METHODS Medical records of patients who received a Thoratec para-corporeal VAD, HeartMate vented electrical VAD, or HeartMate pneumatic VAD between 12/1/97 and 9/1/01 were reviewed. Variables included age, type of devices, total duration of VAD support, discharge status, duration of outpatient support, outcome (transplanted, died on support, ongoing), in-hospital length of stay after transplantation, and complications during VAD support. RESULTS There were 53 device implants in 46 patients. The cumulative patient-days of VAD support was 7,468 (mean duration of support, 138 +/- 195 days; median, 95 days; range, 2 to 948 days). Twenty of the 46 patients were discharged with a VAD. The cumulative outpatient days was 3,600 (mean outpatient duration, 157 +/- 164 days; median, 83 days; maximum, 560 days). Of the 20 outpatients, 11 received cardiac transplantation, 5 died, and 4 are ongoing as of 9/1/01. Major complications that occurred in the outpatient setting included 5 deaths after hospital readmission (1 sepsis, 1 conduit tear, 3 neurologic events); 4 device infections (3 sepsis, 1 pouch infection); and 3 device malfunctions that required reoperation for pump replacement (1 HeartMate pneumatic and 2 HeartMate vented electrical). No deaths occurred in an outpatient setting. CONCLUSIONS Ventricular assist devices effectively support outpatients for months to years. The anticipated time for postoperative recovery and VAD training before discharge is approximately 14 to 21 days, although shorter times may be possible in the future. Establishing a successful outpatient VAD program is a crucial step toward VAD as definitive therapy for end-stage heart disease.

Management of wound and left ventricular assist device pocket infection

Our patient developed a wound infection that involved an implanted left ventricular assist device. At surgery, the pump was washed with a detergent-containing bacteriocidal solution, then antibiotic-impregnated polymethylmethacrylate beads were placed around the pump. The wound was revised using rectus muscle to cover the pump. The incisions have healed and the patient is now at home. She is on no systemic antibiotics and has no evidence of infection 11 months postoperatively.

Palliation of allograft vasculopathy with transluminal angioplasty - a decade of experience

OBJECTIVES The goal of this study was to examine the outcomes of percutaneous coronary interventions (PCI) and the predictors for restenosis after cardiac transplantation. BACKGROUND The role of PCI as definitive therapy for allograft coronary disease (ACD) remains contentious. METHODS Between January 1, 1990 and December 31, 2000, 62 patients (1.5 to 15.5 years after transplant) underwent 151 procedures resulting in PCIs of 219 lesions. Follow-up after PCI angiography was usually obtained at three and six months, then yearly. Repeat PCI was routinely done to lesions with >60% restenosis. RESULTS The primary procedural success was 97%. Repeat PCI occurred in 74 of 219 lesions (34%); PCI-related mortality was 2.6% (4 of 151). The freedom from re-PCI (of same vessel site) was 75% at six months, 65% at one year, and 57% at four years. The freedom from restenosis was 95% at one month, 81% at three months, and 57% at six months. Multivariate predictors of freedom from restenosis were the use of stents, higher anti-proliferative immunosuppressant dose, and an era effect. In the setting of one-vessel disease at first PCI, the two-year freedom for ACD death or graft loss was 74%, compared with 75% for two-vessel and 27% for three-vessel disease (p = 0.009). CONCLUSIONS Despite the increasing effectiveness of PCI for localized ACD, the survival after development of advanced ACD remains poor. Stents appear to increase effectiveness of PCI for ACD, but other factors in the current era contribute to improved outcomes.

The use of bosentan and a prostacyclin analog in the treatment of primary pulmonary hypertension

early (range 3-7 fractions) due to minor marrow suppression or infectious complications. The mean (sd) nadir leukocyte count was 2.98 (1.34) x 10 and platelet nadir 114 (41) x 10. Seven (19%) required blood transfusion and only 2(5%) had serious infections as complications. Duration of TLI course was mean (sd) 62.8 (41.7) days. Mean (sd) rate of decline in FEV1 was 122.7 (21.6) mls/month before TLI and 25.1(7.7) mls/month after TLI, (difference in rate of decline 95% CI 48.2-146.7), p 0.0004 (students paired t-test). Total survival in the 37 treated recipients is median (range) 59 (6-146) months and the post TLI survival is 27 (0-93) months. TLI is a well tolerated treatment with only mild marrow suppression and a low incidence of serious infection. It results in a significant reduction in the rate of FEV1 decline in rapidly progressive BOS. TLI should form part of the immunosuppressive armoury in patients with aggressive BOS.

Response of doxorubicin-induced cardiomyopathy to the current management strategy of heart failure

BACKGROUND Doxorubicin (D) (Adriamycin) is a potent and efficacious chemotherapeutic agent in the treatment of various forms of cancer, but its use has been limited by the development of cardiac toxicity. Historically, D-induced cardiomyopathy (CMP) has been refractory to therapy. We report our experience with this form of CMP at the University of Alabama at Birmingham. METHODS Twenty-five patients (20 women, 5 men) with a clinical diagnosis of D-CMP were referred to our program from 1990 to 2003. Patient data were extracted from office charts. RESULTS Patients were followed-up for 71 +/- 58 months. On presentation, the average left ventricular ejection fraction (LVEF) was 26 +/- 9.2%, and 88% of patients were New York Heart Association (NYHA) Class III or IV. Patients were treated with angiotensin-converting enzyme inhibitors (ACEi; n = 23) or angiotensin-receptor blocker (ARB; n = 2), and 15 were treated with a combination of ACEi and beta-blockers (BB). With medical therapy, LVEF improved significantly (26 +/- 9.2% vs 35 +/- 16.5%, p = 0.022), as did the NYHA class (p < 0.003). All survivors (n = 19) were NYHA Class I or II with medical therapy, with 10 (53%) being Class I. In the group of patients treated with ACEi + BB, there was a statistically significant improvement in LVEF (26 +/- 10.0% vs 37 +/- 17.6%, p = 0.028), which not seen in the ACEi group, with a strong trend toward normalization of LV function (47% vs 10%, p = 0.054). CONCLUSIONS In the current era of management of heart failure, D-CMP carries a better prognosis than previously described. Early addition of BB may further improve LVEF.