Neurologic Complications in Patients with Left Ventricular Assist Devices: Single Institution Retrospective Review.

BACKGROUND: Neurologic complications are common complications encountered by patients with left ventricular assist devices (LVADs). This single-center retrospective study aims to identify the incidence and risk factors of neurologic complications and interventions in patients supported with LVADs and define the associated anticoagulation management. METHODS: Between August 2009 and August 2017, 244 patients underwent LVAD implantation. Twenty-one patients were excluded for having neurologic complications before LVAD placement or for having previously undergone heart transplantation. RESULTS: Fifty-six patients (25%) suffered 61 complications, and 11 (19.6%) died as a result. Gender, type of LVAD, or chronic medical comorbidities evaluated did not contribute to a difference in complication rate; in contrast, length of LVAD implantation was directly related to risk of neurologic complication. Eleven patients (19.6%) underwent 13 surgical interventions including 5 mechanical thrombectomies. Anticoagulation was reversed in 16 patients and held without complication. Anticoagulation was not held for ischemic complications, and no clinically significant hemorrhagic transformation occurred. Intravenous tissue plasminogen activator was also successfully administered to 3 patients without complication. CONCLUSIONS: Neurologic complications were observed in 25% of patients supported with LVADs, of which 20% required neurosurgical intervention. Anticoagulation can be safely withheld in patients with hemorrhagic complications. Patients with ischemic complications can continue to be anticoagulated with no significant risk of hemorrhagic transformation. Length of LVAD implantation was directly related to the risk of neurologic complication. Finally, our study adds to existing literature that mechanical thrombectomy and even intravenous tissue plasminogen activator are options for LVAD patients with ischemic complications.

Driveline Sepsis Presenting As Gout.

In patients with a history of gout, there could be a delay in diagnosis of a septic joint, which increases morbidity and mortality. The literature reports rare instances of coexistent gout and septic arthritis. We present a 64-year-old male with non-ischemic cardiomyopathy, supported by a HeartWare ventricular assist device, who developed a methicillin-resistant Staphylococcus aureus (MRSA) driveline infection four months after device implant. He achieved suppression with minocycline 100 mg by mouth twice a day for five months before presenting to the emergency room with symptoms of gout. Joint aspirate was consistent with a diagnosis of MRSA as well as gout. The patient presented with typical symptoms of a percutaneous driveline infection: soreness at the exit site, erythema, and thick, purulent drainage. Wound culture of the driveline confirmed MRSA and guided antibiotic treatment. His presentation was unusual in that sepsis was identified only after he presented with septic arthritis, which led to the collection of blood cultures. He had no fever, chills, nausea, vomiting, or hypotension. This case illustrates that unresolving gout symptoms after one treatment, in a patient with a known driveline infection, should be further evaluated for possible sepsis and septic arthritis. The patient's unusual presentation of sepsis caused difficulties in diagnosis and management. To our knowledge, this is the first reported case of a driveline infection seeding a joint and causing septic arthritis.