Ultrasound for management of left ventricular assist device driveline infections: A single‐center experience

Driveline infections (DLIs)arethe most frequently encountered left ventricular assist device (LVAD)-specific infections, involving soft tissues surrounding the driveline and presenting with inflammation at the skin exit site. 1 Depending on the depth of soft tissue involvement relativetotheunderlyingmuscle/fascia,DLIscanbeclassifiedassuper-ficial or deep. 1 Computer tomography (CT) is the reference method for DLI’s infection staging, with single-photon emission CT (SPECT) or positron emission tomography (PET)-CT in some circumstances. 2,3 Bedside ultrasound (US) may be a valid alternative to evaluate DLIs. Here we describe the use of US in comparison with CT scan in the management of microbiologically confirmed DLIs in five patients, in all cases, LVAD was implanted as a bridge to transplant (study approved within the Heart Transplant Registry Protocol at Fondazione IRCCS Policlinico San Matteo in Pavia, protocol number 68992/2018, the informed consent was signed by each patients). DLIs were classified according to the Driveline Expert STagINg and carE study group definition. 4 In all patients, US examinations were performed by the same physician (RL) with 10 years of experience in the US using different US equipment (Philips Medical Systems and ESAOTE MyLab xPro80). The presence of fluids, their extension, and depth around the driveline were recorded. US data were also used to monitor the DLI evolution and guide antimicrobial therapy length (antimicrobic treatment was prescribed by the treating physician considering the microbiologic (Supporting Information) and laboratory data, and US characteristicsoftheinfectionsiteovertime.ACTscanwasperformed


L E T T E R T O T H E E D I T O R Ultrasound for management of left ventricular assist device driveline infections: A single-center experience
Dear Editor, Driveline infections (DLIs) are the most frequently encountered left ventricular assist device (LVAD)-specific infections, involving soft tissues surrounding the driveline and presenting with inflammation at the skin exit site. 1 Depending on the depth of soft tissue involvement relative to the underlying muscle/fascia, DLIs can be classified as superficial or deep. 1 Computer tomography (CT) is the reference method for DLI's infection staging, with single-photon emission CT (SPECT) or positron emission tomography (PET)-CT in some circumstances. 2,3dside ultrasound (US) may be a valid alternative to evaluate DLIs.
Here we describe the use of US in comparison with CT scan in the management of microbiologically confirmed DLIs in five patients, in all cases, LVAD was implanted as a bridge to transplant (study approved according to the treating physician's decision, in case of persistence of symptoms or suspicion of deep-seated infection.When available, a comparison between US and CT scan results was performed.A median of 3 DLIs -classified in stage 2B-were recorded for each patient.The US showed purulent exudate within the dermis and its extent around the driveline (range: between 8 and 26 mm) (Figure 1A,C,E), in two cases cutaneous fistulae were documented.In all patients, the US ruled out deeper muscle infections (Figure 1B) or the presence of abscess needing drainage.Five abdominal CT scans in four patients were performed.In all cases, US and CT scans were concordant in excluding a deep-seated infection (Supporting Information).
Infections remain a troublesome issue in the management of patients with LVAD, recurrences are common as in the case of foreign material infections. 2 Randomized, controlled trials to evaluate better therapeutic strategies regarding the management of LVAD infections are lacking.Radiographic investigations are recommended when an infection is suspected; until now only CT, PET-CT, or SPECT have demonstrated a great potential for quantifying the extent of deep VAD-specific infections. 4,5 n our experience, the US precisely showed localized purulent collection around the driveline, excluding the involvement of deep tissue.When a contemporary CT scan was performed, both methods were concordant in ruling out deep infection.The advantages of using US compared to other techniques are the absence of exposure to ionizing radiation and the repeatability of the exam during the follow-up.
within the Heart Transplant Registry Protocol at Fondazione IRCCS Policlinico San Matteo in Pavia, protocol number 68992/2018, the informed consent was signed by each patients).DLIs were classified according to the Driveline Expert STagINg and carE study group definition. 4In all patients, US examinations were performed by the same physician (RL) with 10 years of experience in the US using different US equipment (Philips Medical Systems and ESAOTE MyLab xPro80).The presence of fluids, their extension, and depth around the driveline were recorded.US data were also used to monitor the DLI evolution and guide antimicrobial therapy length (antimicrobic treatment was prescribed by the treating physician considering the microbiologic (Supporting Information) and laboratory data, and US characteristics of the infection site over time.A CT scan was performed List of Abbreviations: CT, computer tomography; DLI, driveline infection; LVAD, left ventricular assist device; PET-CT, positron emission tomography; SPECT, single-photon emission computer tomography; US, ultrasound.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.© 2023 The Authors.Transplant Infectious Disease published by Wiley Periodicals LLC.

F I G U R E 1
An ultrasound (US) showing purulent exudate (white arrows) within the dermis around the driveline (A,C,E), deeper involvement was excluded following the driveline until its passage into the thoracic cavity (B).Comparison between US and computed tomography (CT) scan images in two patients showing purulent collection or subcutaneous inhomogeneity (white arrows C-D, E-F).