Beyond the Achilles Heel: Driveline infection as the cancer of durable LVAD therapy

Durable left ventricular assist devices (LVADs) have transformed survival in advanced heart failure, yet driveline infection (DLI) affects 40% of patients by 5 years. The term "Achilles' heel" identifies the driveline as the system's critical vulnerability but does not capture the course of DLI. Achilles died acutely from a heel wound; DLI is chronic, recurrent, treatment-resistant, and progressive. It begins at the exit site, persists through biofilm formation, recurs after apparent remission, progresses along the driveline, and may eventually involve the pump and outflow graft, repeatedly exposing patients to hospitalizations for intravenous antibiotics and surgery, and ultimately causing death. We therefore propose that DLI be viewed as the "cancer" of LVAD therapy. The analogy is clinical, not biological, and informs treatment: as with cancer, management should be guided by anatomic extent and disease aggressiveness, suppression should not be mistaken for cure, and definitive intervention should precede advanced spread, when source control becomes more difficult. Serial staging and multidisciplinary review are recommended, with hardware removal considered when infection progresses despite suppressive therapy. Potentially curative options for deep DLI include LVAD explantation in patients with sufficient myocardial recovery, transplantation for eligible candidates, and device exchange when transplantation is not feasible. Given the major challenges of treating DLI, every LVAD program must prioritize protocolized prevention from implantation throughout support. Ultimately, eliminating the cancer of LVAD therapy will require a fully implantable system with no driveline to infect.