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Fungal infections in left ventricular assist device recipients. Incidence, prophylaxis, and treatment
D J Goldstein1, N G el-Amir, R C Ashton
1Division of Cardiothoracic Surgery, College of Physicians & Surgeons, Columbia University, New York, USA.
Abstract:
The authors reviewed the charts of 26 recipients of a left ventricular assist device to determine the incidence of fungal infections and the clinical course of these patients. Nine patients (35%) had positive fungal cultures. Of these, six had clinical infections and three were colonized asymptomatically. Three of the six infected patients (including one with mediastinal sepsis and another requiring left ventricular assist device replacement for intractable fungemia) underwent orthotopic heart transplantation after successful therapy. Of the remaining three, one died of a thromboembolic stroke (probably septic in nature), one died secondary to driveline rupture, and the third succumbed to culture-negative sepsis. Two of the colonized patients underwent transplantation, and the third succumbed to perioperative right sided circulatory failure and hypoxia. Positive fungal cultures were a common finding in our series. Because of a significant incidence of fungal infection-related morbidity, the authors revised their pre operative and post operative protocol to include: 1) 2 weeks of fluconazole therapy (200 mg intravenously daily) for patients receiving broad spectrum antibiotics and for those with evidence of preoperative fungal colonization; 2) daily dressing changes around drivelines; 3) daily nystatin swish and swallow; and 4) empiric fluconazole treatment for culture-negative sepsis. Using this protocol, three left ventricular assist device recipients received prophylactic fluconazole and had no evidence of fungal morbidity or mortality on short-term follow-up.
Insights
Fungal infections are common in left ventricular assist device recipients, causing significant morbidity and mortality. A revised protocol including antifungal prophylaxis and improved care reduced fungal complications in a small patient group.
Area of Science:
- Cardiology
- Infectious Diseases
- Medical Devices
Background:
- Left ventricular assist devices (LVADs) are crucial for end-stage heart failure.
- Fungal infections pose a significant risk to LVAD recipients.
- Understanding the incidence and impact of fungal infections is vital for patient management.
Purpose of the Study:
- To determine the incidence of fungal infections in LVAD recipients.
- To analyze the clinical course and outcomes of patients with fungal infections.
- To evaluate the effectiveness of a revised protocol for fungal infection prevention and treatment.
Main Methods:
- Retrospective chart review of 26 LVAD recipients.
- Analysis of fungal culture results and clinical data.
- Implementation and short-term follow-up of a revised pre- and post-operative protocol.
Main Results:
- 35% of patients had positive fungal cultures; 6 had clinical infections, 3 were colonized.
- Fungal infections were associated with severe complications, including sepsis, device replacement, and death.
- The revised protocol, including fluconazole prophylaxis, showed no fungal morbidity or mortality in three treated LVAD recipients.
Conclusions:
- Fungal infections are a common and serious complication in LVAD recipients.
- A comprehensive protocol involving antifungal prophylaxis and enhanced care is effective in reducing fungal-related morbidity and mortality.
- Proactive management of fungal colonization and infection is essential for improving outcomes in LVAD patients.