title: LVAD bloodstream infections: therapeutic rationale for transplantation after LVAD infection.
abstract: BACKGROUND
  Patients who have ventricular assist devices (VADs) and experience bloodstream infection (BSI) have high mortality. We addressed 2 questions raised by the United Network for Organ Sharing (UNOS) priority policy for this problem: 1) Are organs wasted on this ultra-high-risk group? 2) Can device-related BSI be differentiated from transient BSI?
  
  
  METHODS
  Patients with VADs who underwent heart transplantation from 1987 to 2001, who had BSI during VAD support, and who had positive cultures at VAD explant (device-related BSI, n = 10) were compared with those with negative cultures at explant (non-device-related BSI, n = 11).
  
  
  RESULTS
  Patients with device-related BSI had an 80% (8/10) rate of persistent bacteremia; 30 days and 1 year after transplantation, mortality was 14% and 26%, respectively. Non-device-related BSI (n = 11) persisted in 18% (2/11); peri-operative and 1-year mortalities were 9% and 13%. Duration of VAD support predicted infection (132 vs 48 days, p < 0.001); hypo-albuminemia (2.9 +/- 0.5 mg/dl vs 3.3 +/- 0.8 mg/dl, p < 0.05), and a resistant organism predicted a device-related BSI. These patients had increased intubation requirements and had increased creatinine concentration during the first post-operative week, with no difference in liver function, blood loss, transfusions (packed red blood cells, fresh frozen plasma, or platelets), or hemodynamic stability vs patients with non-device BSI. Despite decreased immunosuppression, we found no difference in acute rejection events with device-related BSI. Re-infection with the pre-operative organism occurred in only 1 patient per group.
  
  
  CONCLUSIONS
  These data suggest that urgent (Status 1A) cardiac transplantation is effective in stable patients with device-related BSI, and these data support the current UNOS policy. However, an extra-device source of BSI should be excluded by considering the isolated organism, the baseline nutritional status, and other risk factors.
authors.affiliation: Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Poston
authors.forename: Shahid
authors.initials: S
authors.lastname: Husain
authors.forename: Damian
authors.initials: D
authors.lastname: Sorce
authors.forename: Ellieen
authors.initials: E
authors.lastname: Stanford
authors.forename: Shimon
authors.initials: S
authors.lastname: Kusne
authors.forename: Margaret
authors.initials: M
authors.lastname: Wagener
authors.forename: Bartley P
authors.initials: BP
authors.lastname: Griffith
authors.forename: Robert L
authors.initials: RL
authors.lastname: Kormos
mesh_terms: D016470:Bacteremia / Q000175:diagnosis* / Q000209:etiology* / Q000601:surgery; D020878:Device Removal; D003937:Diagnosis, Differential; D005260:Female; D016027:Heart Transplantation; D006353:Heart-Assist Devices / Q000009:adverse effects* / Q000382:microbiology*; D006801:Humans; D008297:Male; D018579:Patient Selection; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000401:mortality / Q000628:therapy*