Expanding Use of New Technology Creates New Challenges in Preventing and Managing Infections: a Review of Diagnostic and Management Considerations for Infections Among Patients with Long-Term Invasive Devices for Advanced Heart Failure

Although still a relatively new technology, long-term left ventricular assist devices (LVADs) for management of advanced heart failure is rapidly increasing. Initially designed as a bridge to transplant, these invasive devices are increasingly used as a destination therapy, creating unique and long-term infection risks. The aim of this comprehensive review is to highlight current evidence about the prevention, diagnosis, and management of LVAD-specific infections. There are two recent, major societal guidelines (The International Society for Heart and Lung Transplantation, 2017, and the American Society of Transplantation, 2019) specifically on the diagnosis and management of infections in LVAD patients. A third guideline from the European Association for Cardio-Thoracic Surgery (2019) on general LVAD management contains a section on infection management. Recommendations tend to be concordant across the guidelines without major disagreements and suggest that for superficial infections, limited-course durations of antimicrobials are acceptable. For infections of deeper portions of the device, long-term antimicrobial regimens, often with chronic suppressive strategies remain the mainstay of treatment; however, this recommendation is based primarily on expert opinion as high-quality evidence to support best practices remains limited. The role of surgical management remains unknown. Management of long-term, device-related infections in patients with advanced heart failure is challenging and should include input from a multi-disciplinary team of providers to determine the best management strategy. A strong emphasis on best prevention practices is a necessity. With this relatively new technology, evidence-based data to guide best practices remains limited and is an important area of future research.