Alamouti-fard, Emad

Abstract Backgound Infections of the left ventricular assist device (LVAD) driveline are a dreaded complication that results in high mortality and morbidity. Method We retrospectively reviewed five consecutive patients with severe continuous‐flow LVAD (HVAD, Heartmate 2, and Heartmate 3) driveline infection. These infections, which developed on an average of 960.4 ± 843.9 days after LVAD placement, were refractory to systemic antibiotics and local wound care. All were treated with extensive surgical debridement, local installation of absorbable antibiotic‐loaded calcium sulfate beads (vancomycin and tobramycin), primary wound closure, and 6 weeks of systemic antibiotics after surgery. Results Four patients had resolution of DLI, and one had a recurrent infection at another part of the driveline 7 months after the complete resolution of the previous site. This patient was successfully treated with debridement and bead placements. Three patients still have their LVADs, while two received orthotopic heart transplants. At the time of the transplant, there was no evidence of gross infection of the LVAD drivelines or pumps. At the average follow‐up time of 425.8 ± 151 days, no patients have an active infection. Conclusion Treatment of LVAD driveline infection with absorbable antibiotic beads with primary wound closure is a viable option and merits further investigation.

High blood pressure is a potential adjustable risk factor for vascular complications of diabetes. Numerous categories of anti-hypertensive medications have proven to effectively reduce these complications. Additionally, metformin, besides lowering glucose and lipid levels, has advantages on vascular blood flow and improving endothelial function. In this review, we investigate the potential benefits of metformin in lowering blood pressure. Previous studies suggested that the administration of metformin to non-diabetic patients could efficiently reduce systolic blood pressure. The whole comparison of the evidence shows that metformin may have small effects on lowering blood pressure; however, this effect is not directly via a change in sympathetic activity. Mechanisms of blood pressure reduction by metformin may be due to its indirect effects on insulin resistance, nephroprotective, cardioprotective, improvement of the sympatric nerve system, and endothelial function.

Coronavirus (COVID-19) infection exposes patients with heart failure to a higher risk of morbidity and mortality. In LVAD patients, one of the key problems that can lead to life-threatening low-flow or pump malfunction due to thrombus development in the inflow cannula, device body, or outflow graft, implicating hemodynamic instability, hemolysis, renal or hepatic failure, or cerebral or peripheral thromboembolism. [Endothelial protein C receptor and thrombomodulin levels are elevated along with procoagulants such as factor VIII, P-selectin, and von Willebrand factor and downregulated along with thrombomodulin as a result of the cytokine storm released by endothelial and immune cells. In general ,](#ref-0013) LVAD thrombosis has been found to occur in 2–13% of adult patients who use current continuous-flow devices. However, LVAD thrombosis due to COVID-19 is underreported and a few cases presented. We present a case of accelerated LVAD outflow thrombosis in the setting of COVID-19 infection with multiorgan failure.

Heart transplant remains the criterion standard treatment for patients in end-stage heart failure. Improvement in the post-heart transplant outcomes in the last decade has contributed to increased demand for organs. Worldwide each year, more than 5000 heart transplants are performed and 50,000 people become candidates for heart transplant. In the last 50 years, there have been several attempts to expand donor criteria to increase the donor pool. Despite making hepatitis C virus, opioid overdose death, old age allowable and changing the allocation system, the gap between supply and demand is widening and unfortunately, thousands die every year waiting due to the critical shortage of organs. New technologies for heart donation after circulatory death have emerged, particularly normothermic regional organ perfusion and ex-vivo heart perfusion using organ care systems. However, these technologies still do not fill the gap. Continuous advancements in areas such as regenerative medicine and xenotransplantation, among others, are needed to overcome the shortage of heart donors for heart transplantation.