**5. Outcomes in LVAD infections**

Clinical outcomes for LVAD implantation have been extensively reviewed (see for example [10, 61, 74, 75]) including for infection. It is estimated that 15% of LVAD recipients die due to infectious complications, with the majority of deaths occurring within the first 30 days of receipt [76]. More than half of the data available for review is for patients receiving CF devices for BTT indications. Overall rates of infection for CF devices in trials and registries with more than 100 patients were follows: local site infections 20–49%; driveline infections 12–22%; pocket infections 2–5%; sepsis 3–36%; other types of infections 26–35% [10]. It is estimated from the INTERMACS registry data [12] that there are 8 infectious complications per 100 patient-months in CF LVAD recipients. The European Registry for Patients with Mechanical Circulatory Support (EUROMACS), a European registry of LVAD recipients includes data from 52 hospitals from 2681 patients with 2947 implants since 2014 [77]. Overall serious infection rates were 6.18 per 100 patient months within the first 3 months of implantation. Three year survival was only 44% in patients with CF devices, and 20% of the deaths were attributable to infections. In a retrospective study of 88 CF LVAD implantations (22% DT) between 2006 and 2014 at the Toronto General Hospital, 129 readmissions occurred, of which 17% were related to infections [78]. Despite this readmission rate (63% with at least one readmission), outcomes were excellent with only 6 deaths. Other analysis of the INTERMACS registry revealed that 19% of LVAD recipients developed a percutaneous site infection within 12 months of receiving a CF LVAD [79]. Ten percent of patients with these infections died, with sepsis being the most common cause of death (26%) [79]. In general, DT is associated with greater infection risk, and recurrence of infection, especially driveline infections. The majority of these infections are driveline infections and outcomes are generally good (reviewed in [80, 81]). Fortunately with infection control techniques, rates of driveline infections appear to be decreasing [82]. Pocket infections are less common but can confer greater risks of morbidity including hemorrhagic stroke [56, 57]. In a large prospective study of infections after cardiac operations, Perrault et al. found that LVAD and transplant patients experienced 5.8 times higher rates of mediastinal infections (95% CI 2.36–14.33) with five times higher readmission and mortality rates [83]. Nearly all cases of LVAD endocarditis will require explanation and replacement of the device as well as prolonged antimicrobial therapy, and the risks associated with these [42]. Outcomes are improving overall however. Among 156 patients who survived more than 4 years in one center, the mean survival was 7 years with ~1 readmission per year [84]. In terms of overall quality of life, 92% of these patients were NYHA Class I or II. The most common reason for readmission was infection (10%).
