Table of Contents
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Credits
Hosts: Sara Dong
Guests, Writing: Alok Nimgaonkar, Rebecca Kumar
Produced by Sara Dong with support from the Infectious Diseases Society of America (IDSA)
Our Guests
Alok Nimgaonkar, MD
Dr. Alok Nimgaonkar is currently a PGY-3 Internal medicine resident at Georgetown, and he will be starting infectious disease fellowship at NYP-Columbia in the summer. He completed medical school at Tufts University School of Medicine in Boston and undergrad at Columbia University in New York.
Rebecca Kumar, MD
Dr. Rebecca Kumar is a Transplant ID attending at MedStar Georgetown University Hospital. In addition to her work with the Transplant ID Early Career Network (TxID ECN), she is the director of the Transplant ID Track for the ID fellowship at Georgetown, and currently serves as President of the Greater Washington Infectious Disease Society. When not at work, she is learning to play the electric keyboard and hanging out with her family.
Culture
Alok – It Was Just an Accident (film)
Rebecca – Turnstile (band)
Consult Notes
Case Summary
62 year old male with HFrEF due to nonischemic cardiomyopathy s/p Heartmate III LVAD insertion 2 years ago who presents with complicated MDR-Pseudomonas infection
Key Points
This episode provides an update on the definitions of related to VAD infection.
- Rebecca previously joined Sara in 2022 for Febrile episode #30 “Shape of My VAD”, where they discussed a case with an overview of ventricular assist devices (VADs)
- At that time, their discussion was based on the 2011 ISHLT (International Society for Heart and Lung Transplantation) working definitions for infections in patients using VADs: Hannan MM, Husain S, Mattner F, et al. Working formulation for the standardization of definitions of infections in patients using ventricular assist devices. J Heart Lung Transplant. 2011;30(4):375-384. doi:10.1016/j.healun.2011.01.717
- Since that time, a new consensus statement was published by ISHLT with new updated definitions for infections in patients receiving mechanical circulatory support (MCS), which encompasses both acute devices and durable devices: Aslam S, Cowger J, Shah P, et al. The International Society for Heart and Lung Transplantation (ISHLT): 2024 infection definitions for durable and acute mechanical circulatory support devices. J Heart Lung Transplant. 2024;43(7):1039-1050. doi:10.1016/j.healun.2024.03.004
- Mechanical Circulatory Support (MCS) = refers to devices that enhance systemic perfusion in patients with cardiogenic shock or advanced heart failure refractory to pharmacologic interventions
- MCS systems can be classified into short term and long-term support devices
- Short term devices are used to support patients through high risk procedures or afford time to understand prognosis, guide definitive treatment, or as for bridge to transplant these include Impella, intra-aortic balloon pump, or ECMO
- Long term support devices (otherwise known as durable MCS) are typically used for patients with end-stage heart failure and as either bridge to transplant, bridge to decision on transplant (in case of temporary complications), bridge to recovery (occurs in 1-3% of patients) or destination therapy. These devices include LVADs, which we discussed in this episode, as well as biventricular assist devices or total artificial heart implantation
- Alok and Rebecca discussed some of the challenges of the 2011 definitions and the rationale for the update:
- Although the proposed definitions in 2011 were an attempt to standardize definitions in this population, differences persisted between the proposed ISHLT definitions and those adopted by both VAD registries and MCS academic research groups
- The field of durable MCS also evolved, particularly with newer technology that allows intrapericardial pumps that do not require a pump pocket for durable devices. The use of acute MCS support devices as also grown dramatically over that decade
- Additionally, the categorization of deep vs superficial for driveline infections often did not capture the complexity of treatment – for example, a superficial driveline site infection due to an MDRO or a fungus is more complex than a simple susceptible bacterial superinfection
How has the long-term durability of LVADs impacted patient’s ability to move up on the waitlist? And why is this an issue if LVAD outcomes have improved at a comparable level to that of transplants?
- Before 2018, UNOS (United Network for Organ Sharing) listed patients with LVADs as either status 1A if they had complications, or 1B if they did not (excluding dischargeable LVADs)
- In 2018, UNOS deprioritized patients with long term LVADs such that only those with a life-threatening ventricular arrhythmia (status 1) or device malfunction or mechanical failure (status 2) could be greater than status 3; all candidates with device infections could thus only be status 3 at the highest.
- This meant that long term LVAD patients would only be considered for transplant if they developed a serious complication —> sometimes thought of as “bridge to complication”
- UNOS’ recently proposed changes to waitlist designation based on the time a long term LVAD has been in place rather than based on complications!
- Candidates with an LVAD for 6 years would be eligible for status 3 and candidates with an LVAD for 8 years would be eligible for status 2, regardless of their complications.
- OPTN Policy Change for Escalation of Status for Time on LVAD: https://www.hrsa.gov/sites/default/files/hrsa/optn/heart_escl-of-status-for-time-on-lvad_policy-notice_pnjune2025.pdf
- Maitra NS, Dugger SJ, Balachandran IC, Civitello AB, Khazanie P, Rogers JG. Impact of the 2018 UNOS Heart Transplant Policy Changes on Patient Outcomes. JACC Heart Fail. 2023;11(5):491-503. doi:10.1016/j.jchf.2023.01.009
Infographics
Goal
Listeners will be able to define and discuss management of ventricular assist device infections
Learning Objectives
After listening to this episode, listeners will be able to:
- Compare and contrast the 2011 ISHLT (International Society for Heart and Lung Transplantation) working definitions for infections in patients with ventricular assist devices (VADs) vs the newer 2024 definitions for durable and acute mechanical circulatory support devices
- Describe the upcoming policy change that will allow escalation of heart transplant listing status for time with LVAD
- Discuss the initial management of VAD-specific infections
Disclosures
Our guests as well as Febrile podcast and hosts report no relevant financial disclosures
Citation
Nimgaonkar, A., Kumar, R., Dong, S. “#133: Pump and Circumstance: an update on VAD/MCS infections”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/0df0ced7-a4cf-4a01-81cf-112308140f12/